MEDICARE: BLAZE IOM READING, PLLC

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	2084N0400X	Neurology Physician

General Provider Information

NPI Number	:	1992179394
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	BLAZE IOM READING, PLLC

Provider Business Mailing Address
First Line	:	3102 MAPLE AVE STE 450
Second Line	:
City	:	DALLAS
State	:	TX
Zip	:	75201-1261
Country	:	US
Telephone Number	:	281-346-3480
Fax Number	:

Provider Business Practice Location Address
First Line	:	1511 ONYX CIR
Second Line	:
City	:	LONGMONT
State	:	CO
Zip	:	80504-7805
Country	:	US
Telephone Number	:	713-500-7128
Fax Number	:

Authorized Official
Title or Position	:	CEO
Name	:	DR. BRUCE KATUNA
Credential	:
Telephone Number	:	713-500-7128

Provider Enumeration Date	:	11/23/2015
Last Update Date	:	11/28/2018

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