Provider Demographics
NPI:1790054377
Name:BLANCO, JAVIER EDGAR
Entity Type:Individual
Prefix:MR
First Name:JAVIER
Middle Name:EDGAR
Last Name:BLANCO
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 1:572 N. ARROWHEAD ST.
Mailing Address - Street 2:SUITE 100
Mailing Address - City:SAN BERNARDINO
Mailing Address - State:CA
Mailing Address - Zip Code:92410
Mailing Address - Country:US
Mailing Address - Phone:909-266-2700
Mailing Address - Fax:909-266-2790
Practice Address - Street 1:572 N. ARROWHEAD ST.
Practice Address - Street 2:SUITE 100
Practice Address - City:SAN BERNARDINO
Practice Address - State:CA
Practice Address - Zip Code:92410
Practice Address - Country:US
Practice Address - Phone:909-266-2700
Practice Address - Fax:909-266-2790
Is Sole Proprietor?:Yes
Enumeration Date:2011-12-28
Last Update Date:2011-12-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171M00000XOther Service ProvidersCase Manager/Care Coordinator