Provider Demographics
NPI:1982459434
Name:BLAIQ SERVICES
Entity Type:Organization
Organization Name:BLAIQ SERVICES
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:SURGICAL ASSISTANT CERTIFIED
Authorized Official - Prefix:
Authorized Official - First Name:JUSTIN
Authorized Official - Middle Name:
Authorized Official - Last Name:DUHARTE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:916-952-5532
Mailing Address - Street 1:4711 S INDIAN RIVER DR
Mailing Address - Street 2:
Mailing Address - City:FORT PIERCE
Mailing Address - State:FL
Mailing Address - Zip Code:34982-7769
Mailing Address - Country:US
Mailing Address - Phone:916-952-5532
Mailing Address - Fax:
Practice Address - Street 1:4711 S INDIAN RIVER DR
Practice Address - Street 2:
Practice Address - City:FORT PIERCE
Practice Address - State:FL
Practice Address - Zip Code:34982-7769
Practice Address - Country:US
Practice Address - Phone:916-952-5532
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2024-04-18
Last Update Date:2024-04-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363AS0400XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantSurgicalGroup - Multi-Specialty
No261QA1903XAmbulatory Health Care FacilitiesClinic/CenterAmbulatory Surgical