Provider Demographics
NPI:1154067494
Name:BLANCO, DANIEL III (LMT)
Entity Type:Individual
Prefix:MR
First Name:DANIEL
Middle Name:
Last Name:BLANCO
Suffix:III
Gender:M
Credentials:LMT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:48 ELM ST
Mailing Address - Street 2:
Mailing Address - City:WEST ORANGE
Mailing Address - State:NJ
Mailing Address - Zip Code:07052-5910
Mailing Address - Country:US
Mailing Address - Phone:646-784-1084
Mailing Address - Fax:
Practice Address - Street 1:48 ELM ST
Practice Address - Street 2:
Practice Address - City:WEST ORANGE
Practice Address - State:NJ
Practice Address - Zip Code:07052-5910
Practice Address - Country:US
Practice Address - Phone:646-784-1084
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-05-10
Last Update Date:2022-05-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ18KT01338700225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist