Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 111NR0400X | Rehabilitation Chiropractor | CH 8075 | FL |
NPI | 1164696845 |
---|---|
Provider Name | Dr. Stephen Anthony Ballistrea |
First Address | Bayonet Point, FL 34667-6749 |
Second Address | Bayonet Point, FL 34667-6789 |
Gender | M |
NPI Entity type | Individual |
Is Sole Proprietor | No |
Is Organization Subpart | N/A |
Enumeration Date | 14/04/2008 |
Last Update Date | 08/02/2011 |
IDENTIFIER | TYPE / CODE | IDENTIFIER STATE |
---|---|---|
U86609 0001 | (02) | FL |