Provider Demographics
NPI:1427509009
Name:BLACKBURN, CHAD B (HIS)
Entity type:Individual
Prefix:
First Name:CHAD
Middle Name:B
Last Name:BLACKBURN
Suffix:
Gender:M
Credentials:HIS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 238
Mailing Address - Street 2:
Mailing Address - City:SCOTTSBLUFF
Mailing Address - State:NE
Mailing Address - Zip Code:69363-0238
Mailing Address - Country:US
Mailing Address - Phone:308-632-5633
Mailing Address - Fax:308-632-5939
Practice Address - Street 1:106 W 27TH ST
Practice Address - Street 2:
Practice Address - City:SCOTTSBLUFF
Practice Address - State:NE
Practice Address - Zip Code:69361-4304
Practice Address - Country:US
Practice Address - Phone:308-632-5633
Practice Address - Fax:308-632-5939
Is Sole Proprietor?:No
Enumeration Date:2016-10-19
Last Update Date:2016-10-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WY189237700000X
NE800237700000X
AZHAD8556237700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes237700000XSpeech, Language and Hearing Service ProvidersHearing Instrument Specialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NE237700000XMedicaid