Basic Information
| Provider Information | |||||||||
| NPI: | 1457428401 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | BLANTON | ||||||||
| FirstName: | DIANA | ||||||||
| MiddleName: | EDWARDS | ||||||||
| NamePrefix: | MRS. | ||||||||
| NameSuffix: | |||||||||
| Credential: | PT | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | GRICE | ||||||||
| OtherFirstName: | DIANA | ||||||||
| OtherMiddleName: | EDWARDS | ||||||||
| OtherNamePrefix: | MRS. | ||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | |||||||||
| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | 160 IVIE TRAIL | ||||||||
| Address2: | |||||||||
| City: | COLUMBUS | ||||||||
| State: | NC | ||||||||
| PostalCode: | 28722 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8288632850 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 101 HOSPITAL DRIVE | ||||||||
| Address2: | ST LUKES HOSPITAL | ||||||||
| City: | COLUMBUS | ||||||||
| State: | NC | ||||||||
| PostalCode: | 287226418 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8288943311 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 11/28/2006 | ||||||||
| LastUpdateDate: | 07/08/2007 | ||||||||
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| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | F | ||||||||
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| AuthorizedOfficialMiddleName: | |||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 225100000X | 000663 | NC | Y | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Physical Therapist |
No ID Information.