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NPI Code Detail

MEDICARE: EQUINOX LLC

MEDICARE: EQUINOX 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
1207Q00000XFamily Medicine Physician

General Provider Information

NPI Number : 1942407465
Entity Type Code : Organization
Provider Name (Legal Business Name) : EQUINOX LLC
Provider Business Mailing Address
First Line : 705 WASHINGTON ST
Second Line :
City : RAVENSWOOD
State : WV
Zip : 26164-1729
Country : US
Telephone Number : 304-868-6000
Fax Number : 304-868-6002
Provider Business Practice Location Address
First Line : 705 WASHINGTON ST
Second Line :
City : RAVENSWOOD
State : WV
Zip : 26164-1729
Country : US
Telephone Number : 304-868-6000
Fax Number : 304-868-6002
Authorized Official
Title or Position : PRESIDENT
Name : RICHARD J. BLACKBURN
Credential : DO
Telephone Number : 304-868-6000
Provider Enumeration Date : 06/28/2007
Last Update Date : 10/16/2007

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Directions to “EQUINOX LLC ” Practice Location

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