Provider Demographics
NPI:1164036018
Name:BLACKMON, EDDIE III (RRT)
Entity Type:Individual
Prefix:
First Name:EDDIE
Middle Name:
Last Name:BLACKMON
Suffix:III
Gender:M
Credentials:RRT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7309 PETROL ST APT 11
Mailing Address - Street 2:
Mailing Address - City:PARAMOUNT
Mailing Address - State:CA
Mailing Address - Zip Code:90723-3399
Mailing Address - Country:US
Mailing Address - Phone:424-381-3626
Mailing Address - Fax:
Practice Address - Street 1:25820 NORMANDIE AVE
Practice Address - Street 2:
Practice Address - City:HARBOR CITY
Practice Address - State:CA
Practice Address - Zip Code:90710
Practice Address - Country:US
Practice Address - Phone:310-325-5111
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-09-08
Last Update Date:2020-09-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA41213227900000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes227900000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersRespiratory Therapist, Registered