Healthcare Provider Details

I. General information

NPI: 1740882141
Provider Name (Legal Business Name): BLAIR SOLBERGER RD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/10/2020
Last Update Date: 11/10/2020
Certification Date: 11/10/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5501 29TH ST N # A
LEALMAN FL
33714-1819
US

IV. Provider business mailing address

5501 29TH ST N # A
LEALMAN FL
33714-1819
US

V. Phone/Fax

Practice location:
  • Phone: 850-294-3175
  • Fax:
Mailing address:
  • Phone: 850-294-3175
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code133VN1004X
TaxonomyPediatric Nutrition Registered Dietitian
License NumberND8790
License Number StateFL
# 2
Primary TaxonomyN
Taxonomy Code133VN1201X
TaxonomyObesity and Weight Management Nutrition Registered Dietitian
License NumberND8790
License Number StateFL
# 3
Primary TaxonomyN
Taxonomy Code133VN1501X
TaxonomySports Dietetics Nutrition Registered Dietitian
License NumberND8790
License Number StateFL
# 4
Primary TaxonomyY
Taxonomy Code133V00000X
TaxonomyRegistered Dietitian
License NumberND8790
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: