Healthcare Provider Details

I. General information

NPI: 1659772416
Provider Name (Legal Business Name): BRANDON BLACKBURN
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 09/11/2014
Last Update Date: 09/11/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3230 WISCONSIN AVE
JOPLIN MO
64804-4029
US

IV. Provider business mailing address

PO BOX 2526
JOPLIN MO
64803-2526
US

V. Phone/Fax

Practice location:
  • Phone: 417-347-7580
  • Fax: 417-347-0293
Mailing address:
  • Phone: 417-347-7579
  • Fax: 417-347-0293

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code171M00000X
TaxonomyCase Manager/Care Coordinator
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: