Provider Demographics
NPI:1598176653
Name:BLALOCK, OLIVIA PAIGE (RD)
Entity Type:Individual
Prefix:MRS
First Name:OLIVIA
Middle Name:PAIGE
Last Name:BLALOCK
Suffix:
Gender:F
Credentials:RD
Other - Prefix:MS
Other - First Name:OLIVIA
Other - Middle Name:PAIGE
Other - Last Name:ST. CYR
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:501 DR MICHAEL DEBAKEY DR
Mailing Address - Street 2:
Mailing Address - City:LAKE CHARLES
Mailing Address - State:LA
Mailing Address - Zip Code:70601-5724
Mailing Address - Country:US
Mailing Address - Phone:337-312-8258
Mailing Address - Fax:337-312-6708
Practice Address - Street 1:1727 IMPERIAL BLVD
Practice Address - Street 2:BUILDING 2
Practice Address - City:LAKE CHARLES
Practice Address - State:LA
Practice Address - Zip Code:70605-5362
Practice Address - Country:US
Practice Address - Phone:337-310-3670
Practice Address - Fax:337-421-1408
Is Sole Proprietor?:No
Enumeration Date:2014-05-12
Last Update Date:2017-03-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA2541133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered
Provider Identifiers
StateIdentifier IDID TypeIssuer
LA358811YH5NMedicare PIN