Basic Information
| Provider Information | |||||||||
| NPI: | 1023300548 | ||||||||
| EntityType: | 1 | ||||||||
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| LastName: | LADD | ||||||||
| FirstName: | BLAINE | ||||||||
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| Mailing Information | |||||||||
| Address1: | 2496 CRESTVIEW DR | ||||||||
| Address2: | |||||||||
| City: | SANTA CLARA | ||||||||
| State: | UT | ||||||||
| PostalCode: | 847655557 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4355748670 | ||||||||
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| Practice Location | |||||||||
| Address1: | 474 W 200 N | ||||||||
| Address2: | |||||||||
| City: | SAINT GEORGE | ||||||||
| State: | UT | ||||||||
| PostalCode: | 847704505 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4356345660 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 05/03/2011 | ||||||||
| LastUpdateDate: | 05/03/2011 | ||||||||
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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 | 247200000X | Y | Technologists, Technicians & Other Technical Service Providers | Technician, Other |
No ID Information.