1881002392 NPI number — COBY JEANNE PATRICE BLANCO LAT, ATC

Table of content: COBY JEANNE PATRICE BLANCO LAT, ATC (NPI 1881002392)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1881002392 NPI number — COBY JEANNE PATRICE BLANCO LAT, ATC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
BLANCO
Provider First Name:
COBY
Provider Middle Name:
JEANNE PATRICE
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
LAT, ATC
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
VANDENBERG
Provider Other First Name:
JEANNE
Provider Other Middle Name:
PATRICE
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:
1

NPI Number Information

NPI Number:
1881002392
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
02/20/2020
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
10758 VESTONE ST
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
LAS VEGAS
Provider Business Mailing Address State Name:
NV
Provider Business Mailing Address Postal Code:
89141-0480
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
702-379-8421
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
3121 LAS VEGAS BLVD S
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
LAS VEGAS
Provider Business Practice Location Address State Name:
NV
Provider Business Practice Location Address Postal Code:
89109-1967
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
702-770-3751
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
07/28/2014

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: 2255A2300X , with the licence number:  0506269 , registered in the state of NV ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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





Copyright © 2007-2024 www.npivalidator.com