1154877587 NPI number — CALVIN J. BLASCO

Table of content: (NPI 1154877587)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1154877587 NPI number — CALVIN J. BLASCO

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
CALVIN J. BLASCO
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

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:
1154877587
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
08/26/2016
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
1720 ELLINCOURT DR
Provider Second Line Business Mailing Address:
APT. 10
Provider Business Mailing Address City Name:
SOUTH PASADENA
Provider Business Mailing Address State Name:
CA
Provider Business Mailing Address Postal Code:
91030-2110
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
760-880-2854
Provider Business Mailing Address Fax Number:
619-878-2996

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1720 ELLINCOURT DR
Provider Second Line Business Practice Location Address:
APT. 10
Provider Business Practice Location Address City Name:
SOUTH PASADENA
Provider Business Practice Location Address State Name:
CA
Provider Business Practice Location Address Postal Code:
91030-2110
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
760-880-2854
Provider Business Practice Location Address Fax Number:
619-878-2996
Provider Enumeration Date:
08/26/2016

Additional Information

			
		

Authorized Official

Authorized Official Last Name:
BLASCO
Authorized Official First Name:
CALVIN
Authorized Official Middle Name:
JOHN
Authorized Official Title or Position:
CRNA
Authorized Official Telephone Number:
760-880-2854

Provider Taxonomy Codes

  • Taxonomy code: 261Q00000X , with the licence number:  720477 , registered in the state of CA ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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