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General NPI Number Information
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NPI Number | 1215589882
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Entity Type | Individual
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Provider Name | PAIGE RENAE BLOM OD
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Gender | Female
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Dates
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Enumeration Date | 07/12/2019
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Last Update Date | 07/12/2019
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Provider Practice Location Address
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Address Line | 16860 W WADDELL RD STE 102
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City | SURPRISE
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State | AZ
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Zip | 85388-9621
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Country | US
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Telephone | 602-643-4054
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Fax |
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Provider Business Mailing Address
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Address Line | 12448 W HUMMINGBIRD TER
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City | PEORIA
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State | AZ
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Zip | 85383-2213
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Country | US
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Telephone | 641-780-9925
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Fax |
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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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 | OPT-002360
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License Number State | AZ
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