Healthcare Provider Details

I. General information

NPI: 1164408464
Provider Name (Legal Business Name): EMMETT BLOUNT III IDHS
Entity Type: Individual
Gender: Male
Sole Proprietor: X

II. Dates (important events)

Enumeration Date: 12/19/2005
Last Update Date: 09/11/2025
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1317 BALLAHACK RD SUITE 100
CHESAPEAKE VA
23322-2499
US

IV. Provider business mailing address

1260 SHOTGUN RD
CHESAPEAKE VA
23322-4505
US

V. Phone/Fax

Practice location:
  • Phone: 757-421-8220
  • Fax:
Mailing address:
  • Phone: 757-421-1800
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code1710I1002X
TaxonomyIndependent Duty Corpsman
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code1710I1003X
TaxonomyIndependent Duty Medical Technicians
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: