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General NPI Number Information
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NPI Number | 1336747237
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Entity Type | Organization
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Legal Business Name | INFORMED DYSPHAGIA DIAGNOSTICS LLC
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Dates
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Enumeration Date | 10/13/2020
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Last Update Date | 10/13/2020
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Provider Practice Location Address
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Address Line | 1201 DEREK DR STE 1
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City | HAMMOND
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State | LA
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Zip | 70403-5755
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Country | US
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Telephone | 985-805-2555
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Fax |
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Provider Business Mailing Address
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Address Line | 64300 BULLOCK CREEK RD
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City | KENTWOOD
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State | LA
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Zip | 70444-6284
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Country | US
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Telephone |
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Fax |
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Authorized Official
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Title or Position | OWNER
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Name | WILLIAM BLACKBURN
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Credential |
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Telephone | 203-371-7311
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 235Z00000X
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Taxonomy Name | Speech-Language Pathologist
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License Number |
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License Number State |
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