Provider Demographics
NPI:1043319460
Name:DELMONACHE, BLAISE MITCHELL (DC)
Entity Type:Individual
Prefix:DR
First Name:BLAISE
Middle Name:MITCHELL
Last Name:DELMONACHE
Suffix:
Gender:M
Credentials:DC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3413 S KINGS AVE
Mailing Address - Street 2:SUITE 100
Mailing Address - City:BRANDON
Mailing Address - State:FL
Mailing Address - Zip Code:33511-7780
Mailing Address - Country:US
Mailing Address - Phone:813-684-8489
Mailing Address - Fax:
Practice Address - Street 1:3413 S KINGS AVE
Practice Address - Street 2:SUITE 100
Practice Address - City:BRANDON
Practice Address - State:FL
Practice Address - Zip Code:33511-7780
Practice Address - Country:US
Practice Address - Phone:813-684-8489
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-09-22
Last Update Date:2011-06-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLCH7555111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL381361400Medicaid
FL381361400Medicaid
FLU73145Medicare UPIN