Basic Information
Provider Information
NPI: 1902140916
EntityType: 1
ReplacementNPI:  
OrganizationName:  
LastName: BLOMQUIST
FirstName: MISTY
MiddleName: LYNN
NamePrefix:  
NameSuffix:  
Credential: L.AC
OtherOrganizationName:  
OtherOrganizationType:  
OtherLastName:  
OtherFirstName:  
OtherMiddleName:  
OtherNamePrefix:  
OtherNameSuffix:  
OtherCredential:  
OtherLastNameType:  
Mailing Information
Address1: 559 S EDGEWOOD AVE
Address2:  
City: LOMBARD
State: IL
PostalCode: 601482821
CountryCode: US
TelephoneNumber: 8472261047
FaxNumber:  
Practice Location
Address1: 1244 AMERICAN WAY
Address2:  
City: LIBERTYVILLE
State: IL
PostalCode: 600483936
CountryCode: US
TelephoneNumber: 8475499595
FaxNumber:  
Other Information
ProviderEnumerationDate: 11/15/2012
LastUpdateDate: 11/15/2012
NPIDeactivationReasonCode:  
NPIDeactivationDate:  
NPIReactivationDate:  
ProviderGenderCode: F
AuthorizedOfficialLastName:  
AuthorizedOfficialFirstName:  
AuthorizedOfficialMiddleName:  
AuthorizedOfficialTitleorPosition:  
AuthorizedOfficialTelephone:  
IsSoleProprietor: Y
IsOrganizationSubpart:  
ParentOrganizationLBN:  
AuthorizedOfficialNamePrefix:  
AuthorizedOfficialNameSuffix:  
AuthorizedOfficialCredential:  
NPICertificationDate:  

Taxonomy Information
TaxonomyLicenseStateSwitchTaxonomyGroupTaxonomyTypeTaxonomyClassSubSpecialty
171100000X198001098ILY Other Service ProvidersAcupuncturist 

No ID Information.


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