Provider Demographics
NPI:1558616326
Name:DR. BLAIR M BALL OD
Entity Type:Organization
Organization Name:DR. BLAIR M BALL OD
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MANAGER
Authorized Official - Prefix:MRS
Authorized Official - First Name:LAURIE
Authorized Official - Middle Name:LYN
Authorized Official - Last Name:BALL
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:951-845-0272
Mailing Address - Street 1:1659 E 6TH ST
Mailing Address - Street 2:SUITE A
Mailing Address - City:BEAUMONT
Mailing Address - State:CA
Mailing Address - Zip Code:92223-5765
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1659 E 6TH ST
Practice Address - Street 2:SUITE A
Practice Address - City:BEAUMONT
Practice Address - State:CA
Practice Address - Zip Code:92223-5765
Practice Address - Country:US
Practice Address - Phone:951-845-0272
Practice Address - Fax:951-845-0143
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-07-18
Last Update Date:2015-04-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAOPT 8422 TPL152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CASD0084220Medicaid
CA0421440001Medicare NSC
CASD0084220Medicaid