Provider Demographics
NPI:1306326715
Name:HARBOURNE, BLAINE (ND)
Entity type:Individual
Prefix:DR
First Name:BLAINE
Middle Name:
Last Name:HARBOURNE
Suffix:
Gender:M
Credentials:ND
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1230 SAINT JAMES PL APT 1A
Mailing Address - Street 2:
Mailing Address - City:GLEN ELLYN
Mailing Address - State:IL
Mailing Address - Zip Code:60137-7804
Mailing Address - Country:US
Mailing Address - Phone:586-246-1480
Mailing Address - Fax:
Practice Address - Street 1:486 S SPRING RD
Practice Address - Street 2:
Practice Address - City:ELMHURST
Practice Address - State:IL
Practice Address - Zip Code:60126-3858
Practice Address - Country:US
Practice Address - Phone:586-246-1480
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-08-15
Last Update Date:2018-08-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL164007341133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered