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General NPI Number Information
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NPI Number | 1124375498
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Entity Type | Organization
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Legal Business Name | CARL J BLACKBURN OD LLC
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Dates
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Enumeration Date | 08/06/2012
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Last Update Date | 03/19/2013
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Provider Practice Location Address
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Address Line | 5655 E SAM HOUSTON PKWY N
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City | HOUSTON
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State | TX
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Zip | 77015-3250
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Country | US
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Telephone | 713-450-4484
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Fax | 713-450-4424
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Provider Business Mailing Address
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Address Line | 7619 DOLPHIN ARC DR
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City | HUMBLE
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State | TX
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Zip | 77346-8199
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Country | US
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Telephone | 281-852-4440
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Fax |
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Authorized Official
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Title or Position | OWNER / SOLE MEMBER
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Name | DR. CARL JOSEPH BLACKBURN
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Credential | O.D.
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Telephone | 281-852-4440
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 152W00000X
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Taxonomy Name | Optometrist
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License Number | 1771TG
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License Number State | TX
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