Provider Demographics
NPI:1124609813
Name:LLOYD, IAN BLAZER
Entity type:Individual
Prefix:
First Name:IAN
Middle Name:BLAZER
Last Name:LLOYD
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 1:1850 SPRING RIDGE DR
Mailing Address - Street 2:
Mailing Address - City:SUSANVILLE
Mailing Address - State:CA
Mailing Address - Zip Code:96130-6100
Mailing Address - Country:US
Mailing Address - Phone:530-257-7094
Mailing Address - Fax:
Practice Address - Street 1:1850 SPRING RIDGE DR
Practice Address - Street 2:
Practice Address - City:SUSANVILLE
Practice Address - State:CA
Practice Address - Zip Code:96130-6100
Practice Address - Country:US
Practice Address - Phone:530-257-7094
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-04-15
Last Update Date:2021-04-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
1078568133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered