1700206901 NPI number — STAN R. BLACKWELL A.B.O.C.

NPI Number: 1700206901
Health Care Provider/Practitioner: STAN R. BLACKWELL A.B.O.C.

NPI Number : 1700206901 – JSON Data Format

                
{
  "Npi": {
    "NPI": "1700206901",
    "EntityType": "Individual",
    "ReplacementNPI": null,
    "EIN": null,
    "IsSoleProprietor": "Y",
    "IsOrgSubpart": null,
    "ParentOrgLBN": null,
    "ParentOrgTIN": null,
    "OrgName": null,
    "LastName": "BLACKWELL",
    "FirstName": "STAN",
    "MiddleName": "R.",
    "NamePrefix": "MR.",
    "NameSuffix": null,
    "Credential": "A.B.O.C.",
    "OtherOrgName": null,
    "OtherOrgNameTypeCode": null,
    "OtherLastName": "POWELL",
    "OtherFirstName": "STANLEY",
    "OtherMiddleName": "REED",
    "OtherNamePrefix": "MR.",
    "OtherNameSuffix": "JR.",
    "OtherCredential": "SR.AIRMAN USAF",
    "OtherLastNameTypeCode": "1",
    "FirstLineMailingAddress": "3178 W LINDACITA LN",
    "SecondLineMailingAddress": null,
    "MailingAddressCityName": "ANAHEIM",
    "MailingAddressStateName": "CA",
    "MailingAddressPostalCode": "92804-1725",
    "MailingAddressCountryCode": "US",
    "MailingAddressTelephoneNumber": "714-743-5544",
    "MailingAddressFaxNumber": null,
    "FirstLinePracticeLocationAddress": "10612 LOS ALAMITOS BLVD",
    "SecondLinePracticeLocationAddress": null,
    "PracticeLocationAddressCityName": "LOS ALAMITOS",
    "PracticeLocationAddressStateName": "CA",
    "PracticeLocationAddressPostalCode": "90720-2116",
    "PracticeLocationAddressCountryCode": "US",
    "PracticeLocationAddressTelephoneNumber": "562-493-3569",
    "PracticeLocationAddressFaxNumber": "562-596-8948",
    "EnumerationDate": "04/26/2014",
    "LastUpdateDate": "04/26/2014",
    "NPIDeactivationReasonCode": null,
    "NPIDeactivationReason": null,
    "NPIDeactivationDate": null,
    "NPIReactivationDate": null,
    "GenderCode": "M",
    "Gender": "Male",
    "AuthorizedOfficialLastName": null,
    "AuthorizedOfficialFirstName": null,
    "AuthorizedOfficialMiddleName": null,
    "AuthorizedOfficialTitle": null,
    "AuthorizedOfficialNamePrefix": null,
    "AuthorizedOfficialNameSuffix": null,
    "AuthorizedOfficialCredential": null,
    "AuthorizedOfficialTelephoneNumber": null,
    "Taxonomies": {
      "Taxonomy": {
        "TaxonomyCode": "156FX1800X",
        "TaxonomyName": "Optician",
        "LicenseNumber": "SL2639",
        "LicenseNumberStateCode": "CA",
        "PrimaryTaxonomySwitch": "Y"
      }
    },
    "HealthcareProviderTaxonomyGroups": null
  }
}