Provider Demographics
NPI:1841901196
Name:BLANCO, RAFAEL (DC)
Entity type:Individual
Prefix:DR
First Name:RAFAEL
Middle Name:
Last Name:BLANCO
Suffix:
Gender:M
Credentials:DC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1710 AVENIDA DEL MUNDO UNIT 504
Mailing Address - Street 2:
Mailing Address - City:CORONADO
Mailing Address - State:CA
Mailing Address - Zip Code:92118-3065
Mailing Address - Country:US
Mailing Address - Phone:619-874-5607
Mailing Address - Fax:
Practice Address - Street 1:8555 STATION VILLAGE LN STE B
Practice Address - Street 2:
Practice Address - City:SAN DIEGO
Practice Address - State:CA
Practice Address - Zip Code:92108-6567
Practice Address - Country:US
Practice Address - Phone:619-486-3044
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-12-07
Last Update Date:2022-12-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA36496111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor