Provider Demographics
NPI:1669978599
Name:BLACKWELL, IRA
Entity type:Individual
Prefix:
First Name:IRA
Middle Name:
Last Name:BLACKWELL
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 1:28 FAMILY WAY LANE
Mailing Address - Street 2:
Mailing Address - City:HEATHSVILLE
Mailing Address - State:VA
Mailing Address - Zip Code:22473
Mailing Address - Country:US
Mailing Address - Phone:804-580-8117
Mailing Address - Fax:
Practice Address - Street 1:28 FAMILY WAY LANE
Practice Address - Street 2:
Practice Address - City:HEATHSVILLE
Practice Address - State:VA
Practice Address - Zip Code:22473
Practice Address - Country:US
Practice Address - Phone:804-580-8117
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-03-31
Last Update Date:2018-03-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VAT66908696343900000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes343900000XTransportation ServicesNon-emergency Medical Transport (VAN)