Healthcare Provider Details

I. General information

NPI: 1740046002
Provider Name (Legal Business Name): MR. JOHN L BLACKSTONE
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 02/26/2024
Last Update Date: 02/26/2024
Certification Date: 02/24/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

205 SILVERSTONE DR
ENGLEWOOD OH
45322-1722
US

IV. Provider business mailing address

205 SILVERSTONE DR
ENGLEWOOD OH
45322-1722
US

V. Phone/Fax

Practice location:
  • Phone: 937-620-8726
  • Fax:
Mailing address:
  • Phone: 937-620-8726
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code347C00000X
TaxonomyPrivate Vehicle
License NumberRQ741430
License Number StateOH
# 2
Primary TaxonomyN
Taxonomy Code3747P1801X
TaxonomyPersonal Care Attendant
License Number
License Number StateNULL
# 3
Primary TaxonomyN
Taxonomy Code253Z00000X
TaxonomyIn Home Supportive Care Agency
License Number
License Number StateNULL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: