Provider Demographics
NPI:1407687767
Name:BLANCO, MARA
Entity type:Individual
Prefix:
First Name:MARA
Middle Name:
Last Name:BLANCO
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3052 CAPISTRANO DR
Mailing Address - Street 2:
Mailing Address - City:MADERA
Mailing Address - State:CA
Mailing Address - Zip Code:93637-8855
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:2811 W CESAR CHAVEZ BLVD
Practice Address - Street 2:
Practice Address - City:FRESNO
Practice Address - State:CA
Practice Address - Zip Code:93706
Practice Address - Country:US
Practice Address - Phone:559-493-4400
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-08-09
Last Update Date:2024-08-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered