Provider Demographics
NPI:1164547519
Name:BLANCO REGIONAL CLINIC, P.A.
Entity Type:Organization
Organization Name:BLANCO REGIONAL CLINIC, P.A.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:JOHN
Authorized Official - Middle Name:D
Authorized Official - Last Name:WEAVER
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:830-833-5581
Mailing Address - Street 1:PO BOX 1629
Mailing Address - Street 2:825 FOURTH STREET
Mailing Address - City:BLANCO
Mailing Address - State:TX
Mailing Address - Zip Code:78606-1629
Mailing Address - Country:US
Mailing Address - Phone:830-833-5581
Mailing Address - Fax:830-833-4933
Practice Address - Street 1:825 4TH ST
Practice Address - Street 2:
Practice Address - City:BLANCO
Practice Address - State:TX
Practice Address - Zip Code:78606-4913
Practice Address - Country:US
Practice Address - Phone:830-833-5581
Practice Address - Fax:830-833-4933
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-03-21
Last Update Date:2008-06-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX080001301Medicaid
TX080001301Medicaid