Provider Demographics
NPI:1518562974
Name:BLANCO, CHARVEL LEE RENEE (LO)
Entity Type:Individual
Prefix:
First Name:CHARVEL
Middle Name:LEE RENEE
Last Name:BLANCO
Suffix:
Gender:F
Credentials:LO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:18 ROYAL OAK RD
Mailing Address - Street 2:
Mailing Address - City:NEW BRITAIN
Mailing Address - State:CT
Mailing Address - Zip Code:06053-1608
Mailing Address - Country:US
Mailing Address - Phone:860-736-4438
Mailing Address - Fax:
Practice Address - Street 1:1013 FARMINGTON AVE
Practice Address - Street 2:
Practice Address - City:WEST HARTFORD
Practice Address - State:CT
Practice Address - Zip Code:06107-2181
Practice Address - Country:US
Practice Address - Phone:860-233-2020
Practice Address - Fax:860-236-9008
Is Sole Proprietor?:No
Enumeration Date:2020-12-03
Last Update Date:2020-12-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT1701156FX1800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes156FX1800XEye and Vision Services ProvidersTechnician/TechnologistOptician