Provider Demographics
NPI:1407396773
Name:TABULA RASA, PLLC
Entity Type:Organization
Organization Name:TABULA RASA, PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:KEVIN
Authorized Official - Middle Name:
Authorized Official - Last Name:BLANKENSHIP
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:681-238-5957
Mailing Address - Street 1:PO BOX 415
Mailing Address - Street 2:
Mailing Address - City:CRAB ORCHARD
Mailing Address - State:WV
Mailing Address - Zip Code:25827-0415
Mailing Address - Country:US
Mailing Address - Phone:681-238-5957
Mailing Address - Fax:681-238-5958
Practice Address - Street 1:1296 ROBERT C. BYRD DRIVE
Practice Address - Street 2:
Practice Address - City:CRAB ORCHARD
Practice Address - State:WV
Practice Address - Zip Code:25827
Practice Address - Country:US
Practice Address - Phone:681-238-5957
Practice Address - Fax:681-238-5958
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2017-03-06
Last Update Date:2017-03-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WV19121305R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes305R00000XManaged Care OrganizationsPreferred Provider Organization