Provider Demographics
NPI:1588231856
Name:BLOSTIC, CHARLES MICHAEL
Entity Type:Individual
Prefix:
First Name:CHARLES
Middle Name:MICHAEL
Last Name:BLOSTIC
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1440 RUSSELL DR
Mailing Address - Street 2:
Mailing Address - City:STREETSBORO
Mailing Address - State:OH
Mailing Address - Zip Code:44241-8330
Mailing Address - Country:US
Mailing Address - Phone:234-284-5561
Mailing Address - Fax:
Practice Address - Street 1:1044 SAGRAMORE DR S
Practice Address - Street 2:
Practice Address - City:STREETSBORO
Practice Address - State:OH
Practice Address - Zip Code:44241-4625
Practice Address - Country:US
Practice Address - Phone:330-842-1917
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-06-07
Last Update Date:2021-06-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes376J00000XNursing Service Related ProvidersHomemaker
No3747P1801XNursing Service Related ProvidersTechnicianPersonal Care Attendant