Provider Demographics
NPI:1164897567
Name:LOLIKA, BLAISE
Entity Type:Individual
Prefix:
First Name:BLAISE
Middle Name:
Last Name:LOLIKA
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3130 S PORTIA AVE
Mailing Address - Street 2:
Mailing Address - City:TUCSON
Mailing Address - State:AZ
Mailing Address - Zip Code:85730-1449
Mailing Address - Country:US
Mailing Address - Phone:520-881-4813
Mailing Address - Fax:
Practice Address - Street 1:3130 S PORTIA AVE
Practice Address - Street 2:
Practice Address - City:TUCSON
Practice Address - State:AZ
Practice Address - Zip Code:85730-1449
Practice Address - Country:US
Practice Address - Phone:520-881-4813
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2015-12-10
Last Update Date:2015-12-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZBH-4758385H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes385H00000XRespite Care FacilityRespite Care
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZBH-4758OtherAZ DEPT OF HEALTH SVCS