Provider Demographics
NPI:1740046002
Name:BLACKSTONE, JOHN L
Entity type:Individual
Prefix:MR
First Name:JOHN
Middle Name:L
Last Name:BLACKSTONE
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 1:205 SILVERSTONE DR
Mailing Address - Street 2:
Mailing Address - City:ENGLEWOOD
Mailing Address - State:OH
Mailing Address - Zip Code:45322-1722
Mailing Address - Country:US
Mailing Address - Phone:937-620-8726
Mailing Address - Fax:
Practice Address - Street 1:205 SILVERSTONE DR
Practice Address - Street 2:
Practice Address - City:ENGLEWOOD
Practice Address - State:OH
Practice Address - Zip Code:45322-1722
Practice Address - Country:US
Practice Address - Phone:937-620-8726
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-02-26
Last Update Date:2024-02-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
253Z00000X, 3747P1801X
OHRQ741430347C00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes347C00000XTransportation ServicesPrivate Vehicle
No253Z00000XAgenciesIn Home Supportive Care
No3747P1801XNursing Service Related ProvidersTechnicianPersonal Care AttendantGroup - Multi-Specialty