Provider Demographics
NPI:1881731495
Name:PAUL D. BLAKELEY CPO
Entity type:Organization
Organization Name:PAUL D. BLAKELEY CPO
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:MR
Authorized Official - First Name:PAUL
Authorized Official - Middle Name:D
Authorized Official - Last Name:BLAKELEY
Authorized Official - Suffix:
Authorized Official - Credentials:CPO FAAOP
Authorized Official - Phone:864-582-4411
Mailing Address - Street 1:102 WILLOW LANE
Mailing Address - Street 2:
Mailing Address - City:SPARTANABURG
Mailing Address - State:SC
Mailing Address - Zip Code:29307
Mailing Address - Country:US
Mailing Address - Phone:864-582-4411
Mailing Address - Fax:864-573-6717
Practice Address - Street 1:102 WILLOW LANE
Practice Address - Street 2:
Practice Address - City:SPARTANABURG
Practice Address - State:SC
Practice Address - Zip Code:29307
Practice Address - Country:US
Practice Address - Phone:864-582-4411
Practice Address - Fax:864-573-6717
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-01-31
Last Update Date:2008-02-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332BC3200XSuppliersDurable Medical Equipment & Medical SuppliesCustomized Equipment
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC7701424Medicaid
SCDME285Medicaid
SC0551550001Medicare NSC