Provider Demographics
NPI:1750691994
Name:BLACKMON, GERALD THEADORE III
Entity type:Individual
Prefix:
First Name:GERALD
Middle Name:THEADORE
Last Name:BLACKMON
Suffix:III
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 1:1665 S MONTE VERDE DR
Mailing Address - Street 2:
Mailing Address - City:BEAUMONT
Mailing Address - State:CA
Mailing Address - Zip Code:92223-8589
Mailing Address - Country:US
Mailing Address - Phone:951-663-6995
Mailing Address - Fax:951-769-5513
Practice Address - Street 1:1665 S MONTE VERDE DR
Practice Address - Street 2:
Practice Address - City:BEAUMONT
Practice Address - State:CA
Practice Address - Zip Code:92223-8589
Practice Address - Country:US
Practice Address - Phone:951-663-6995
Practice Address - Fax:951-769-5513
Is Sole Proprietor?:Yes
Enumeration Date:2010-10-20
Last Update Date:2010-10-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA7202290343900000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes343900000XTransportation ServicesNon-emergency Medical Transport (VAN)