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General NPI Number Information
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NPI Number | 1750231403
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Entity Type | Individual
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Provider Name | BLAINE HAVENS SA-C, TS-C
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Gender | Male
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Dates
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Enumeration Date | 02/02/2026
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Last Update Date | 02/02/2026
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Provider Practice Location Address
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Address Line | 14320 W SIDE BLVD APT 303
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City | LAUREL
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State | MD
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Zip | 20707-6260
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Country | US
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Telephone | 440-941-7716
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Fax |
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Provider Business Mailing Address
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Address Line | 14320 W SIDE BLVD APT 303
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City | LAUREL
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State | MD
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Zip | 20707-6260
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Country | US
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Telephone | 440-941-7716
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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 | 246ZC0007X
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Taxonomy Name | Surgical Assistant
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License Number | 26-125
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License Number State | MD
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