Provider Demographics
NPI:1750398335
Name:BLACKBURN, NADINE
Entity type:Individual
Prefix:
First Name:NADINE
Middle Name:
Last Name:BLACKBURN
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:AAA MEDICAL SUPPLY
Other - Middle Name:
Other - Last Name:SERVICE CTR INC
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:
Mailing Address - Street 1:PO BOX 1013
Mailing Address - Street 2:
Mailing Address - City:MORENO VALLEY
Mailing Address - State:CA
Mailing Address - Zip Code:92556-1013
Mailing Address - Country:US
Mailing Address - Phone:951-488-9111
Mailing Address - Fax:480-445-9790
Practice Address - Street 1:24281 POSTAL AVE
Practice Address - Street 2:211
Practice Address - City:MORENO VALLEY
Practice Address - State:CA
Practice Address - Zip Code:92553-3093
Practice Address - Country:US
Practice Address - Phone:951-488-9111
Practice Address - Fax:480-773-8616
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-03
Last Update Date:2009-04-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA15582332B00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332B00000XSuppliersDurable Medical Equipment & Medical Supplies
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA330620945OtherVA