Provider Demographics
NPI:1629477633
Name:EATON, BLANCHE
Entity Type:Individual
Prefix:
First Name:BLANCHE
Middle Name:
Last Name:EATON
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1502 W BROADWAY AVE
Mailing Address - Street 2:
Mailing Address - City:MINNEAPOLIS
Mailing Address - State:MN
Mailing Address - Zip Code:55411-2408
Mailing Address - Country:US
Mailing Address - Phone:612-529-2399
Mailing Address - Fax:612-529-2399
Practice Address - Street 1:1502 W BROADWAY AVE
Practice Address - Street 2:
Practice Address - City:MINNEAPOLIS
Practice Address - State:MN
Practice Address - Zip Code:55411-2408
Practice Address - Country:US
Practice Address - Phone:612-529-2399
Practice Address - Fax:612-529-2399
Is Sole Proprietor?:Yes
Enumeration Date:2014-08-14
Last Update Date:2014-08-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN3675466305R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes305R00000XManaged Care OrganizationsPreferred Provider Organization