Provider Demographics
NPI:1588092118
Name:BLANCO, DOUGLAS MANUEL
Entity type:Individual
Prefix:
First Name:DOUGLAS
Middle Name:MANUEL
Last Name:BLANCO
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6583 ESCATAWPA BAY CT
Mailing Address - Street 2:
Mailing Address - City:LAS VEGAS
Mailing Address - State:NV
Mailing Address - Zip Code:89122-3513
Mailing Address - Country:US
Mailing Address - Phone:626-549-7244
Mailing Address - Fax:
Practice Address - Street 1:6583 ESCATAWPA BAY CT
Practice Address - Street 2:
Practice Address - City:LAS VEGAS
Practice Address - State:NV
Practice Address - Zip Code:89122-3513
Practice Address - Country:US
Practice Address - Phone:626-549-7244
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2013-10-16
Last Update Date:2013-10-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225400000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersRehabilitation Practitioner