Provider Demographics
NPI:1093560104
Name:BLALOCK, BRANDON ROBERT
Entity type:Individual
Prefix:
First Name:BRANDON
Middle Name:ROBERT
Last Name:BLALOCK
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5799 BROADMOOR ST
Mailing Address - Street 2:
Mailing Address - City:OVERLAND PARK
Mailing Address - State:KS
Mailing Address - Zip Code:66202-2427
Mailing Address - Country:US
Mailing Address - Phone:660-202-7899
Mailing Address - Fax:
Practice Address - Street 1:5799 BROADMOOR ST
Practice Address - Street 2:
Practice Address - City:OVERLAND PARK
Practice Address - State:KS
Practice Address - Zip Code:66202-2427
Practice Address - Country:US
Practice Address - Phone:660-202-7899
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-04-22
Last Update Date:2025-01-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes247200000XTechnologists, Technicians & Other Technical Service ProvidersTechnician, Other