Provider Demographics
NPI:1982364535
Name:INFANTE REYES, BLAS L (MLS(ASCP)MB)
Entity Type:Individual
Prefix:
First Name:BLAS
Middle Name:L
Last Name:INFANTE REYES
Suffix:
Gender:M
Credentials:MLS(ASCP)MB
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 1913
Mailing Address - Street 2:
Mailing Address - City:ANNA MARIA
Mailing Address - State:FL
Mailing Address - Zip Code:34216-1913
Mailing Address - Country:US
Mailing Address - Phone:941-623-9260
Mailing Address - Fax:
Practice Address - Street 1:206 2ND ST E
Practice Address - Street 2:
Practice Address - City:BRADENTON
Practice Address - State:FL
Practice Address - Zip Code:34208-1000
Practice Address - Country:US
Practice Address - Phone:941-263-9260
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-12-22
Last Update Date:2021-12-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NV65629-TCL-0156F00000X
FLTN52013156F00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes156F00000XEye and Vision Services ProvidersTechnician/Technologist