1922076827 NPI number — MR. DION ERICSON BLAKE IDC

Table of content: MR. DION ERICSON BLAKE IDC (NPI 1922076827)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1922076827 NPI number — MR. DION ERICSON BLAKE IDC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
BLAKE
Provider First Name:
DION
Provider Middle Name:
ERICSON
Provider Name Prefix Text:
MR.
Provider Name Suffix Text:
Provider Credential Text:
IDC
Provider Gender Code:
M

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1922076827
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
03/07/2008
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
1035 NW 155TH TER
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
PEMBROKE PINES
Provider Business Mailing Address State Name:
FL
Provider Business Mailing Address Postal Code:
33028-1514
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
954-804-8731
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
USS JOHN L. HALL
Provider Second Line Business Practice Location Address:
FPO AA 34091
Provider Business Practice Location Address City Name:
JACKSONVILLE
Provider Business Practice Location Address State Name:
FL
Provider Business Practice Location Address Postal Code:
32228
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
904-270-6541
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
03/08/2006

Additional Information

			
		

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 1710I1002X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)