Healthcare Provider Details

I. General information

NPI: 1669761391
Provider Name (Legal Business Name): BLAZE VALLEY CORPORATION
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/04/2011
Last Update Date: 01/31/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

974 PINEY GROVE RD
SOMERSET KY
42501-5476
US

IV. Provider business mailing address

974 PINEY GROVE RD
SOMERSET KY
42501-5476
US

V. Phone/Fax

Practice location:
  • Phone: 606-274-0156
  • Fax: 606-274-0234
Mailing address:
  • Phone: 606-274-0156
  • Fax: 606-274-0234

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code332BP3500X
TaxonomyParenteral & Enteral Nutrition Supplies (DME)
License NumberHME00706
License Number StateKY
# 2
Primary TaxonomyY
Taxonomy Code332B00000X
TaxonomyDurable Medical Equipment & Medical Supplies
License Number
License Number State

VIII. Authorized Official

Name: MRS. MARIA L JAYME-MARTIN
Title or Position: PRESIDENT
Credential:
Phone: 606-274-0156