1316116171 NPI number — MS. VIDA LORRAINE BLAKELY MFTT

Table of content: MS. VIDA LORRAINE BLAKELY MFTT (NPI 1316116171)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1316116171 NPI number — MS. VIDA LORRAINE BLAKELY MFTT

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
BLAKELY
Provider First Name:
VIDA
Provider Middle Name:
LORRAINE
Provider Name Prefix Text:
MS.
Provider Name Suffix Text:
Provider Credential Text:
MFTT
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
HARVEY
Provider Other First Name:
VIDA
Provider Other Middle Name:
LORRAINE
Provider Other Name Prefix Text:
MRS.
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:
2

NPI Number Information

NPI Number:
1316116171
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
02/26/2008
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
1227 COUNTRYSIDE LN
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
MANTECA
Provider Business Mailing Address State Name:
CA
Provider Business Mailing Address Postal Code:
95337-6700
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
510-828-3037
Provider Business Mailing Address Fax Number:
209-629-8790

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1700 MCHENRY VILLAGE WAY
Provider Second Line Business Practice Location Address:
SUITE11
Provider Business Practice Location Address City Name:
MODESTO
Provider Business Practice Location Address State Name:
CA
Provider Business Practice Location Address Postal Code:
95350-4308
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
209-526-1476
Provider Business Practice Location Address Fax Number:
209-526-0908
Provider Enumeration Date:
02/26/2008

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: 390200000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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





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