Provider Demographics
NPI:1922208693
Name:LICON, BLANCA E
Entity Type:Individual
Prefix:MRS
First Name:BLANCA
Middle Name:E
Last Name:LICON
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 1:1830 GEORGE DIETER DR STE 103
Mailing Address - Street 2:
Mailing Address - City:EL PASO
Mailing Address - State:TX
Mailing Address - Zip Code:79936-4305
Mailing Address - Country:US
Mailing Address - Phone:915-855-4244
Mailing Address - Fax:915-855-4580
Practice Address - Street 1:1830 GEORGE DIETER DR STE 103
Practice Address - Street 2:
Practice Address - City:EL PASO
Practice Address - State:TX
Practice Address - Zip Code:79936-4305
Practice Address - Country:US
Practice Address - Phone:915-855-4244
Practice Address - Fax:915-855-4580
Is Sole Proprietor?:Yes
Enumeration Date:2007-07-20
Last Update Date:2007-07-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXCP00354156FX1800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes156FX1800XEye and Vision Services ProvidersTechnician/TechnologistOptician