Provider Demographics
NPI:1588628531
Name:BLANTON, JIMMY HERBERT (DC)
Entity Type:Individual
Prefix:DR
First Name:JIMMY
Middle Name:HERBERT
Last Name:BLANTON
Suffix:
Gender:M
Credentials:DC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1216 6TH AVE
Mailing Address - Street 2:
Mailing Address - City:HUNTINGTON
Mailing Address - State:WV
Mailing Address - Zip Code:25701-2312
Mailing Address - Country:US
Mailing Address - Phone:304-523-3333
Mailing Address - Fax:304-523-3330
Practice Address - Street 1:1216 6TH AVE
Practice Address - Street 2:
Practice Address - City:HUNTINGTON
Practice Address - State:WV
Practice Address - Zip Code:25701-2312
Practice Address - Country:US
Practice Address - Phone:304-523-3333
Practice Address - Fax:304-523-3330
Is Sole Proprietor?:No
Enumeration Date:2006-04-14
Last Update Date:2012-08-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WV668111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH2082124Medicaid
WV0132319000Medicaid
KY85680049Medicaid
WV350053238Medicare ID - Type UnspecifiedRAILROAD MEDICARE
KY85680049Medicaid
WV0132319000Medicaid