Provider Demographics
NPI:1700440633
Name:DR. TAYLOR BLADH O.D. INC
Entity Type:Organization
Organization Name:DR. TAYLOR BLADH O.D. INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:TAYLOR
Authorized Official - Middle Name:WOODBURY
Authorized Official - Last Name:BLADH
Authorized Official - Suffix:
Authorized Official - Credentials:OD
Authorized Official - Phone:909-861-3737
Mailing Address - Street 1:1796 NEWPORT BLVD
Mailing Address - Street 2:
Mailing Address - City:COSTA MESA
Mailing Address - State:CA
Mailing Address - Zip Code:92627-2756
Mailing Address - Country:US
Mailing Address - Phone:949-642-2020
Mailing Address - Fax:
Practice Address - Street 1:1796 NEWPORT BLVD
Practice Address - Street 2:
Practice Address - City:COSTA MESA
Practice Address - State:CA
Practice Address - Zip Code:92627-2756
Practice Address - Country:US
Practice Address - Phone:949-642-2020
Practice Address - Fax:949-642-8753
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:DR. TAYLOR BLADH O.D. INC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2019-04-25
Last Update Date:2019-06-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Multi-Specialty
No152WC0802XEye and Vision Services ProvidersOptometristCorneal and Contact ManagementGroup - Multi-Specialty
No152WP0200XEye and Vision Services ProvidersOptometristPediatricsGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAOPT8921TPAOtherOPTOMETRY LICENSE NUMBER