Provider Demographics
NPI:1679896344
Name:JOHN C BLACKENBURG OD LLC
Entity type:Organization
Organization Name:JOHN C BLACKENBURG OD LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:JOHN
Authorized Official - Middle Name:C
Authorized Official - Last Name:BLACKENBURG
Authorized Official - Suffix:
Authorized Official - Credentials:OD
Authorized Official - Phone:251-645-2991
Mailing Address - Street 1:7930 MOFFETT RD
Mailing Address - Street 2:
Mailing Address - City:SEMMES
Mailing Address - State:AL
Mailing Address - Zip Code:36575-5490
Mailing Address - Country:US
Mailing Address - Phone:251-645-2991
Mailing Address - Fax:251-645-0723
Practice Address - Street 1:7930 MOFFETT RD
Practice Address - Street 2:
Practice Address - City:SEMMES
Practice Address - State:AL
Practice Address - Zip Code:36575-5490
Practice Address - Country:US
Practice Address - Phone:251-645-2991
Practice Address - Fax:251-645-0723
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-03-09
Last Update Date:2010-08-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ALS498TA014152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Single Specialty