Provider Demographics
NPI:1174197321
Name:BLANCO, WALDO
Entity Type:Individual
Prefix:
First Name:WALDO
Middle Name:
Last Name:BLANCO
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 1:6560 NW 7TH ST APT 501
Mailing Address - Street 2:
Mailing Address - City:MIAMI
Mailing Address - State:FL
Mailing Address - Zip Code:33126-4476
Mailing Address - Country:US
Mailing Address - Phone:305-676-1565
Mailing Address - Fax:
Practice Address - Street 1:6560 NW 7TH ST APT 501
Practice Address - Street 2:
Practice Address - City:MIAMI
Practice Address - State:FL
Practice Address - Zip Code:33126-4476
Practice Address - Country:US
Practice Address - Phone:305-676-1565
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-05-13
Last Update Date:2021-05-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171M00000XOther Service ProvidersCase Manager/Care Coordinator