Provider Demographics
NPI:1760931836
Name:BLAYLOCK, BRANDON (BS, CNIM)
Entity Type:Individual
Prefix:
First Name:BRANDON
Middle Name:
Last Name:BLAYLOCK
Suffix:
Gender:M
Credentials:BS, CNIM
Other - Prefix:
Other - First Name:ROBERT
Other - Middle Name:BRANDON
Other - Last Name:BLAYLOCK
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:BS, CNIM
Mailing Address - Street 1:9777 W GULF BANK RD
Mailing Address - Street 2:SUITE 5
Mailing Address - City:HOUSTON
Mailing Address - State:TX
Mailing Address - Zip Code:77040-3132
Mailing Address - Country:US
Mailing Address - Phone:281-970-5900
Mailing Address - Fax:
Practice Address - Street 1:9777 W GULF BANK RD
Practice Address - Street 2:SUITE 5
Practice Address - City:HOUSTON
Practice Address - State:TX
Practice Address - Zip Code:77040-3132
Practice Address - Country:US
Practice Address - Phone:281-970-5900
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-09-29
Last Update Date:2016-09-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes246ZE0600XTechnologists, Technicians & Other Technical Service ProvidersSpecialist/Technologist, OtherElectroneurodiagnostic