Healthcare Provider Details

I. General information

NPI: 1801472840
Provider Name (Legal Business Name): MR. CARL RUDOLPH BLAIN
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

Provider Other Name: CARL RUDOLPH BLAIN

II. Dates (important events)

Enumeration Date: 03/21/2021
Last Update Date: 03/21/2021
Certification Date: 03/12/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

28 WORCESTER PL
HOLBROOK MA
02343-1085
US

IV. Provider business mailing address

28 WORCESTER PL
HOLBROOK MA
02343-1085
US

V. Phone/Fax

Practice location:
  • Phone: 857-308-6508
  • Fax:
Mailing address:
  • Phone: 857-308-6508
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QH0100X
TaxonomyHealth Service Clinic/Center
License Number
License Number State

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: