1750398335 NPI number — NADINE BLACKBURN

Table of content: NADINE BLACKBURN (NPI 1750398335)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1750398335 NPI number — NADINE BLACKBURN

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
BLACKBURN
Provider First Name:
NADINE
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
SERVICE CTR INC
Provider Other First Name:
AAA MEDICAL SUPPLY
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:
5

NPI Number Information

NPI Number:
1750398335
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
04/20/2009
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 1013
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
MORENO VALLEY
Provider Business Mailing Address State Name:
CA
Provider Business Mailing Address Postal Code:
92556-1013
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
951-488-9111
Provider Business Mailing Address Fax Number:
480-445-9790

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
24281 POSTAL AVE
Provider Second Line Business Practice Location Address:
211
Provider Business Practice Location Address City Name:
MORENO VALLEY
Provider Business Practice Location Address State Name:
CA
Provider Business Practice Location Address Postal Code:
92553-3093
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
951-488-9111
Provider Business Practice Location Address Fax Number:
480-773-8616
Provider Enumeration Date:
08/03/2006

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: 332B00000X , with the licence number:  15582 , 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)

  • Identifier: 330620945 . This is a "VA" identifier , issued by the state of ( CA ) . This identifiers is of the category "OTHER".




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