Healthcare Provider Details

I. General information

NPI: 1932522711
Provider Name (Legal Business Name): FERNAN BLANCO
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 01/29/2014
Last Update Date: 01/29/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

175 FONTAINEBLEAU BLVD SUITE 2 G 1
MIAMI FL
33172-7018
US

IV. Provider business mailing address

175 FONTAINEBLEAU BLVD SUITE 2 G 1
MIAMI FL
33172-7018
US

V. Phone/Fax

Practice location:
  • Phone: 305-603-9983
  • Fax:
Mailing address:
  • Phone: 305-603-9983
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2471C3402X
TaxonomyRadiography Radiologic Technologist
License NumberBMO59003
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: