Provider Demographics
NPI:1750602090
Name:BLOMQUIST, CHAD ALAN (LMT)
Entity type:Individual
Prefix:
First Name:CHAD
Middle Name:ALAN
Last Name:BLOMQUIST
Suffix:
Gender:M
Credentials:LMT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1114 17TH AVE
Mailing Address - Street 2:
Mailing Address - City:MOLINE
Mailing Address - State:IL
Mailing Address - Zip Code:61265-3868
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:6860 SAINT EDMUNDS LOOP
Practice Address - Street 2:
Practice Address - City:FORT MYERS
Practice Address - State:FL
Practice Address - Zip Code:33966-7503
Practice Address - Country:US
Practice Address - Phone:309-948-3213
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2010-06-22
Last Update Date:2024-11-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IA005795225700000X
IL227.010795225700000X
FLMA102775225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist