Provider Demographics
NPI:1558697029
Name:BLAS, JOSE RIOS JR (OTA)
Entity Type:Individual
Prefix:MR
First Name:JOSE
Middle Name:RIOS
Last Name:BLAS
Suffix:JR
Gender:M
Credentials:OTA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:419 E HIGH ST
Mailing Address - Street 2:
Mailing Address - City:MONTICELLO
Mailing Address - State:IL
Mailing Address - Zip Code:61856-1457
Mailing Address - Country:US
Mailing Address - Phone:217-762-3397
Mailing Address - Fax:
Practice Address - Street 1:444 W HARRISON AVE
Practice Address - Street 2:
Practice Address - City:DECATUR
Practice Address - State:IL
Practice Address - Zip Code:62526-4157
Practice Address - Country:US
Practice Address - Phone:217-877-7333
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2009-10-19
Last Update Date:2009-10-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL057001368224Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes224Z00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapy Assistant