Provider Demographics
NPI:1417724501
Name:MEDINA, BLANCA I
Entity type:Individual
Prefix:
First Name:BLANCA
Middle Name:I
Last Name:MEDINA
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 1:21585 CENTER RIDGE RD APT 116
Mailing Address - Street 2:
Mailing Address - City:ROCKY RIVER
Mailing Address - State:OH
Mailing Address - Zip Code:44116-3912
Mailing Address - Country:US
Mailing Address - Phone:216-256-7640
Mailing Address - Fax:
Practice Address - Street 1:21245 LORAIN RD STE 150
Practice Address - Street 2:
Practice Address - City:FAIRVIEW PARK
Practice Address - State:OH
Practice Address - Zip Code:44126-2196
Practice Address - Country:US
Practice Address - Phone:216-256-7640
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-12-08
Last Update Date:2024-12-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH33.024177225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist