Healthcare Provider Details

I. General information

NPI: 1770404063
Provider Name (Legal Business Name): 4EVERBLAZIN ENT LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/22/2026
Last Update Date: 09/25/2026
Certification Date: 09/25/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1443 - 1449 E MAIN ST # A22
ROCHESTER NY
14609-7003
US

IV. Provider business mailing address

PO BOX 26333
ROCHESTER NY
14626-0333
US

V. Phone/Fax

Practice location:
  • Phone: 585-353-4857
  • Fax:
Mailing address:
  • Phone: 585-353-4857
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code171M00000X
TaxonomyCase Manager/Care Coordinator
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code172V00000X
TaxonomyCommunity Health Worker
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code175T00000X
TaxonomyPeer Specialist
License Number
License Number State
# 4
Primary TaxonomyY
Taxonomy Code251B00000X
TaxonomyCase Management Agency
License Number
License Number State
# 5
Primary TaxonomyN
Taxonomy Code372600000X
TaxonomyAdult Companion
License Number
License Number State

VIII. Authorized Official

Name: INSHA ALSTON
Title or Position: OWNER
Credential:
Phone: 585-353-4857