Healthcare Provider Details

I. General information

NPI: 1033849690
Provider Name (Legal Business Name): DAVID GLENN BLACKMON HAS
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/15/2022
Last Update Date: 06/15/2022
Certification Date: 06/15/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6218 US HIGHWAY 301 N
ELLENTON FL
34222-3065
US

IV. Provider business mailing address

3813 GULF BLVD APT 312
ST PETE BEACH FL
33706-3924
US

V. Phone/Fax

Practice location:
  • Phone: 941-722-7200
  • Fax:
Mailing address:
  • Phone: 513-616-8888
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code237700000X
TaxonomyHearing Instrument Specialist
License NumberAS5648
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: