Provider Demographics
NPI:1528410776
Name:BLINN, BRIAN (LAC)
Entity Type:Individual
Prefix:
First Name:BRIAN
Middle Name:
Last Name:BLINN
Suffix:
Gender:M
Credentials:LAC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1261 LINCOLN AVE STE 205
Mailing Address - Street 2:
Mailing Address - City:SAN JOSE
Mailing Address - State:CA
Mailing Address - Zip Code:95125-3031
Mailing Address - Country:US
Mailing Address - Phone:831-428-5616
Mailing Address - Fax:
Practice Address - Street 1:1261 LINCOLN AVE STE 205
Practice Address - Street 2:
Practice Address - City:SAN JOSE
Practice Address - State:CA
Practice Address - Zip Code:95125-3031
Practice Address - Country:US
Practice Address - Phone:831-428-5616
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-07-11
Last Update Date:2018-03-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAAC17112171100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171100000XOther Service ProvidersAcupuncturist