MEDICARE: BLAZING INDIGO LLC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	213ES0103X	Foot & Ankle Surgery Podiatrist	1521	TX
2	213ES0103X	Foot & Ankle Surgery Podiatrist	1412	TX

General Provider Information

NPI Number	:	1306161567
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	BLAZING INDIGO LLC

Provider Business Mailing Address
First Line	:	409 W FM 495
Second Line	:
City	:	SAN JUAN
State	:	TX
Zip	:	78589-3717
Country	:	US
Telephone Number	:	956-782-6200
Fax Number	:	956-782-6202

Provider Business Practice Location Address
First Line	:	409 W FM 495
Second Line	:
City	:	SAN JUAN
State	:	TX
Zip	:	78589-3717
Country	:	US
Telephone Number	:	956-782-6200
Fax Number	:	956-782-6202

Authorized Official
Title or Position	:	CEO
Name	:	MRS. NATASHA E BELTRE
Credential	:
Telephone Number	:	956-782-6200

Provider Enumeration Date	:	03/31/2010
Last Update Date	:	03/31/2010

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Directions to “BLAZING INDIGO LLC ” Practice Location

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