Provider Demographics
NPI:1447904305
Name:SANCHEZ, BLAIZE
Entity type:Individual
Prefix:
First Name:BLAIZE
Middle Name:
Last Name:SANCHEZ
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:522 GREAT BEND DR
Mailing Address - Street 2:
Mailing Address - City:DIAMOND BAR
Mailing Address - State:CA
Mailing Address - Zip Code:91765-2031
Mailing Address - Country:US
Mailing Address - Phone:909-841-7882
Mailing Address - Fax:
Practice Address - Street 1:12249 OXNARD ST APT 101
Practice Address - Street 2:
Practice Address - City:NORTH HOLLYWOOD
Practice Address - State:CA
Practice Address - Zip Code:91606-4689
Practice Address - Country:US
Practice Address - Phone:909-841-7882
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-02-09
Last Update Date:2022-02-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA54218225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist