Healthcare Provider Details

I. General information

NPI: 1528394368
Provider Name (Legal Business Name): ROBERT EARL BLOUNT N/A
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 10/29/2009
Last Update Date: 10/29/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

600 COMMON ST
SHREVEPORT LA
71101-3432
US

IV. Provider business mailing address

PO BOX 80165 600 COMMON ST
SHREVEPORT LA
71148-0165
US

V. Phone/Fax

Practice location:
  • Phone: 318-425-6213
  • Fax: 318-221-3750
Mailing address:
  • Phone: 318-347-2208
  • Fax: 318-221-3750

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code172V00000X
TaxonomyCommunity Health Worker
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code174H00000X
TaxonomyHealth Educator
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: