Healthcare Provider Details

I. General information

NPI: 1386288413
Provider Name (Legal Business Name): DOREEN BLAIR
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 11/01/2019
Last Update Date: 11/01/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

110 YELLOW SPRINGS RD
ELIZABETHTOWN IL
62931-4447
US

IV. Provider business mailing address

110 YELLOW SPRINGS RD
ELIZABETHTOWN IL
62931-4447
US

V. Phone/Fax

Practice location:
  • Phone: 618-289-4339
  • Fax:
Mailing address:
  • Phone: 618-289-4339
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code3747A0650X
TaxonomyAttendant Care Provider
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code3747A0650X
TaxonomyAttendant Care Provider
License Number
License Number StateMO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: