Basic Information
| Provider Information | |||||||||
| NPI: | 1992179394 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | BLAZE IOM READING, PLLC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 3102 MAPLE AVE STE 450 | ||||||||
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| City: | DALLAS | ||||||||
| State: | TX | ||||||||
| PostalCode: | 752011261 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2813463480 | ||||||||
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| Practice Location | |||||||||
| Address1: | 1511 ONYX CIR | ||||||||
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| City: | LONGMONT | ||||||||
| State: | CO | ||||||||
| PostalCode: | 805047805 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7135007128 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 11/23/2015 | ||||||||
| LastUpdateDate: | 11/28/2018 | ||||||||
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| AuthorizedOfficialLastName: | KATUNA | ||||||||
| AuthorizedOfficialFirstName: | BRUCE | ||||||||
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| AuthorizedOfficialTitleorPosition: | CEO | ||||||||
| AuthorizedOfficialTelephone: | 7135007128 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | DR. | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 2084N0400X | Y | 193400000X SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Psychiatry & Neurology | Neurology |
No ID Information.