Provider Demographics
NPI:1487917993
Name:INNER BALANCE INTEGRATIVE MEDICINE, LLC
Entity type:Organization
Organization Name:INNER BALANCE INTEGRATIVE MEDICINE, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:JOHN
Authorized Official - Middle Name:
Authorized Official - Last Name:BORDIUK
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:781-454-9014
Mailing Address - Street 1:65 WALNUT ST
Mailing Address - Street 2:SUITE 380
Mailing Address - City:WELLESLEY
Mailing Address - State:MA
Mailing Address - Zip Code:02481-2118
Mailing Address - Country:US
Mailing Address - Phone:781-454-9014
Mailing Address - Fax:
Practice Address - Street 1:65 WALNUT ST
Practice Address - Street 2:SUITE 380
Practice Address - City:WELLESLEY
Practice Address - State:MA
Practice Address - Zip Code:02481-2118
Practice Address - Country:US
Practice Address - Phone:781-239-9900
Practice Address - Fax:781-239-9953
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-06-19
Last Update Date:2013-04-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA77100207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MA22D2048592OtherCLIA CERTIFICATION
MAA2097601Medicare PIN