Provider Demographics
NPI:1306161567
Name:BLAZING INDIGO LLC
Entity type:Organization
Organization Name:BLAZING INDIGO LLC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:MRS
Authorized Official - First Name:NATASHA
Authorized Official - Middle Name:E
Authorized Official - Last Name:BELTRE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:956-782-6200
Mailing Address - Street 1:409 W FM 495
Mailing Address - Street 2:
Mailing Address - City:SAN JUAN
Mailing Address - State:TX
Mailing Address - Zip Code:78589-3717
Mailing Address - Country:US
Mailing Address - Phone:956-782-6200
Mailing Address - Fax:956-782-6202
Practice Address - Street 1:409 W FM 495
Practice Address - Street 2:
Practice Address - City:SAN JUAN
Practice Address - State:TX
Practice Address - Zip Code:78589-3717
Practice Address - Country:US
Practice Address - Phone:956-782-6200
Practice Address - Fax:956-782-6202
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-03-31
Last Update Date:2010-03-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX1521213ES0103X
TX1412213ES0103X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes213ES0103XPodiatric Medicine & Surgery Service ProvidersPodiatristFoot & Ankle SurgeryGroup - Single Specialty