Provider Demographics
NPI:1679963185
Name:BLALOCK, JOHN WAYLAN (DC)
Entity type:Individual
Prefix:
First Name:JOHN
Middle Name:WAYLAN
Last Name:BLALOCK
Suffix:
Gender:M
Credentials:DC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:523 MAIN ST
Mailing Address - Street 2:
Mailing Address - City:EL SEGUNDO
Mailing Address - State:CA
Mailing Address - Zip Code:90245-3006
Mailing Address - Country:US
Mailing Address - Phone:310-322-0912
Mailing Address - Fax:310-322-6872
Practice Address - Street 1:523 MAIN ST
Practice Address - Street 2:
Practice Address - City:EL SEGUNDO
Practice Address - State:CA
Practice Address - Zip Code:90245-3006
Practice Address - Country:US
Practice Address - Phone:310-322-0912
Practice Address - Fax:310-322-6872
Is Sole Proprietor?:Yes
Enumeration Date:2015-02-04
Last Update Date:2015-02-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA33163111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor