Healthcare Provider Details

I. General information

NPI: 1083296289
Provider Name (Legal Business Name): BLAIR MADLAND MILO DC
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 04/27/2021
Last Update Date: 04/27/2021
Certification Date: 04/27/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3151 AIRWAY AVE STE U3
COSTA MESA CA
92626-4627
US

IV. Provider business mailing address

1801 E 15TH ST APT C
NEWPORT BEACH CA
92663-5365
US

V. Phone/Fax

Practice location:
  • Phone: 714-754-8008
  • Fax:
Mailing address:
  • Phone: 706-817-2691
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code111N00000X
TaxonomyChiropractor
License Number34830
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: