Basic Information
| Provider Information | |||||||||
| NPI: | 1346648987 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | BLACKBURN | ||||||||
| FirstName: | CASEY | ||||||||
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| Mailing Information | |||||||||
| Address1: | 614 N 11TH ST | ||||||||
| Address2: | |||||||||
| City: | SAN JOSE | ||||||||
| State: | CA | ||||||||
| PostalCode: | 951123220 | ||||||||
| CountryCode: | US | ||||||||
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| Practice Location | |||||||||
| Address1: | 2001 THE ALAMEDA | ||||||||
| Address2: | |||||||||
| City: | SAN JOSE | ||||||||
| State: | CA | ||||||||
| PostalCode: | 951261136 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4082617777 | ||||||||
| FaxNumber: | 4082592273 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 12/14/2014 | ||||||||
| LastUpdateDate: | 12/14/2014 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 174400000X | 111097739 | TN | Y | Other Service Providers | Specialist |
No ID Information.