Provider Demographics
NPI:1972771103
Name:BLANCO- DIEBOLD, CENDRY (LMT)
Entity Type:Individual
Prefix:MRS
First Name:CENDRY
Middle Name:
Last Name:BLANCO- DIEBOLD
Suffix:
Gender:F
Credentials:LMT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:24 WHITTLESEY LN
Mailing Address - Street 2:
Mailing Address - City:PALM COAST
Mailing Address - State:FL
Mailing Address - Zip Code:32164-3941
Mailing Address - Country:US
Mailing Address - Phone:386-586-8124
Mailing Address - Fax:
Practice Address - Street 1:24 WHITTLESEY LN
Practice Address - Street 2:
Practice Address - City:PALM COAST
Practice Address - State:FL
Practice Address - Zip Code:32164-3941
Practice Address - Country:US
Practice Address - Phone:386-586-8124
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2008-02-11
Last Update Date:2008-02-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLMA38220225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist