Healthcare Provider Details

I. General information

NPI: 1811407109
Provider Name (Legal Business Name): MRS. BROOKE LORRAINE BLOMBERG
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: BROOKE LORRAINE CONLIN

II. Dates (important events)

Enumeration Date: 10/02/2017
Last Update Date: 10/02/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

27699 JEFFERSON AVE
TEMECULA CA
92590-2661
US

IV. Provider business mailing address

10392 GLEN ROCK CIR
MORENO VALLEY CA
92557-2692
US

V. Phone/Fax

Practice location:
  • Phone: 951-695-4688
  • Fax:
Mailing address:
  • Phone: 951-903-6931
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number
License Number StateCA
# 2
Primary TaxonomyN
Taxonomy Code146N00000X
TaxonomyBasic Emergency Medical Technician
License NumberB2084708
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: