Provider Demographics
NPI:1578980991
Name:BLAISDELL, DAVID (CPO, LPO)
Entity Type:Individual
Prefix:
First Name:DAVID
Middle Name:
Last Name:BLAISDELL
Suffix:
Gender:M
Credentials:CPO, LPO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:949 STEVENS DR
Mailing Address - Street 2:
Mailing Address - City:RICHLAND
Mailing Address - State:WA
Mailing Address - Zip Code:99352-3508
Mailing Address - Country:US
Mailing Address - Phone:509-946-2520
Mailing Address - Fax:509-946-2520
Practice Address - Street 1:949 STEVENS DR
Practice Address - Street 2:
Practice Address - City:RICHLAND
Practice Address - State:WA
Practice Address - Zip Code:99352-3508
Practice Address - Country:US
Practice Address - Phone:509-946-2520
Practice Address - Fax:509-946-2530
Is Sole Proprietor?:Yes
Enumeration Date:2014-03-24
Last Update Date:2014-03-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAPS00000468335E00000X
WAOI00000469335E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes335E00000XSuppliersProsthetic/Orthotic Supplier