Healthcare Provider Details

I. General information

NPI: 1760854327
Provider Name (Legal Business Name): GERALD BLACKMON
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/22/2015
Last Update Date: 10/22/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

908 N 3RD ST
MONROE LA
71201-5844
US

IV. Provider business mailing address

908 N 3RD ST
MONROE LA
71201-5844
US

V. Phone/Fax

Practice location:
  • Phone: 318-547-2312
  • Fax: 318-325-8749
Mailing address:
  • Phone: 318-547-2312
  • Fax: 318-325-8749

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101Y00000X
TaxonomyCounselor
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: