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General NPI Number Information
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NPI Number | 1700117082
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Entity Type | Organization
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Legal Business Name | BLACKWELL HOMES
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Dates
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Enumeration Date | 01/26/2010
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Last Update Date | 01/26/2010
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Provider Practice Location Address
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Address Line | 1646 S WRIGHT RD
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City | SANTA ROSA
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State | CA
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Zip | 95407-7318
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Country | US
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Telephone | 707-575-5387
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Fax | 707-570-2647
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Provider Business Mailing Address
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Address Line | PO BOX 8578
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City | SANTA ROSA
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State | CA
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Zip | 95407-1578
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Country | US
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Telephone | 707-575-5387
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Fax | 707-570-2647
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Authorized Official
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Title or Position | CFO
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Name | MR. WILLARD BLACKWELL
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Credential | MA
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Telephone | 707-575-5387
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 261QD1600X
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Taxonomy Name | Developmental Disabilities Clinic/Center
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License Number | 496800053
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License Number State | CA
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