Healthcare Provider Details

I. General information

NPI: 1477447795
Provider Name (Legal Business Name): PRESLEY BLACKMON
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/03/2025
Last Update Date: 06/03/2025
Certification Date: 06/03/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1655 TAMIAMI TRL
PORT CHARLOTTE FL
33948-1042
US

IV. Provider business mailing address

4041 TAGGART CAY N APT 206
SARASOTA FL
34233-4813
US

V. Phone/Fax

Practice location:
  • Phone: 941-623-4918
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code237700000X
TaxonomyHearing Instrument Specialist
License NumberAS5897
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: