MEDICARE: BLAIQ SERVICES

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	261QA1903X	Ambulatory Surgical Clinic/Center
2	363AS0400X	Surgical Physician Assistant

General Provider Information

NPI Number	:	1982459434
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	BLAIQ SERVICES

Provider Business Mailing Address
First Line	:	4711 S INDIAN RIVER DR
Second Line	:
City	:	FORT PIERCE
State	:	FL
Zip	:	34982-7769
Country	:	US
Telephone Number	:	916-952-5532
Fax Number	:

Provider Business Practice Location Address
First Line	:	4711 S INDIAN RIVER DR
Second Line	:
City	:	FORT PIERCE
State	:	FL
Zip	:	34982-7769
Country	:	US
Telephone Number	:	916-952-5532
Fax Number	:

Authorized Official
Title or Position	:	SURGICAL ASSISTANT CERTIFIED
Name	:	JUSTIN DUHARTE
Credential	:
Telephone Number	:	916-952-5532

Provider Enumeration Date	:	04/18/2024
Last Update Date	:	04/20/2024

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Directions to “BLAIQ SERVICES ” Practice Location

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