Basic Information
| Provider Information | |||||||||
| NPI: | 1003933979 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | BLAIR | ||||||||
| FirstName: | BRENT | ||||||||
| MiddleName: | |||||||||
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| Credential: | MA | ||||||||
| OtherOrganizationName: | |||||||||
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| Mailing Information | |||||||||
| Address1: | 643 GRANT ST APT F | ||||||||
| Address2: | |||||||||
| City: | SANTA MONICA | ||||||||
| State: | CA | ||||||||
| PostalCode: | 904051248 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3233562552 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 1200 WILSHIRE BLVD STE 500 | ||||||||
| Address2: | |||||||||
| City: | LOS ANGELES | ||||||||
| State: | CA | ||||||||
| PostalCode: | 900171934 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2134817464 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 03/23/2007 | ||||||||
| LastUpdateDate: | 07/08/2007 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 171W00000X | Y | Other Service Providers | Contractor |
No ID Information.