Provider Demographics
NPI:1265831549
Name:BLANKSON, ODARTEY
Entity Type:Individual
Prefix:
First Name:ODARTEY
Middle Name:
Last Name:BLANKSON
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 1:47 E AGATE AVE UNIT 204
Mailing Address - Street 2:
Mailing Address - City:LAS VEGAS
Mailing Address - State:NV
Mailing Address - Zip Code:89123-6060
Mailing Address - Country:US
Mailing Address - Phone:708-646-6933
Mailing Address - Fax:
Practice Address - Street 1:47 E AGATE AVE UNIT 204
Practice Address - Street 2:
Practice Address - City:LAS VEGAS
Practice Address - State:NV
Practice Address - Zip Code:89123-6060
Practice Address - Country:US
Practice Address - Phone:708-646-6933
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2014-08-22
Last Update Date:2014-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NV225400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225400000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersRehabilitation Practitioner