Provider Demographics
NPI:1598345597
Name:SEGURA, BLAIN (MAT, ATC)
Entity type:Individual
Prefix:
First Name:BLAIN
Middle Name:
Last Name:SEGURA
Suffix:
Gender:M
Credentials:MAT, ATC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1401 REED CANAL RD UNIT 1201
Mailing Address - Street 2:
Mailing Address - City:PORT ORANGE
Mailing Address - State:FL
Mailing Address - Zip Code:32129-9415
Mailing Address - Country:US
Mailing Address - Phone:772-233-5351
Mailing Address - Fax:
Practice Address - Street 1:1401 REED CANAL RD UNIT 1201
Practice Address - Street 2:
Practice Address - City:PORT ORANGE
Practice Address - State:FL
Practice Address - Zip Code:32129-9415
Practice Address - Country:US
Practice Address - Phone:772-233-5351
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-04-13
Last Update Date:2024-06-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
2255A2300X, 390200000X
AL66482255A2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program