Provider Demographics
NPI:1700117082
Name:BLACKWELL HOMES
Entity type:Organization
Organization Name:BLACKWELL HOMES
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CFO
Authorized Official - Prefix:MR
Authorized Official - First Name:WILLARD
Authorized Official - Middle Name:
Authorized Official - Last Name:BLACKWELL
Authorized Official - Suffix:
Authorized Official - Credentials:MA
Authorized Official - Phone:707-575-5387
Mailing Address - Street 1:PO BOX 8578
Mailing Address - Street 2:
Mailing Address - City:SANTA ROSA
Mailing Address - State:CA
Mailing Address - Zip Code:95407-1578
Mailing Address - Country:US
Mailing Address - Phone:707-575-5387
Mailing Address - Fax:707-570-2647
Practice Address - Street 1:1646 S WRIGHT RD
Practice Address - Street 2:
Practice Address - City:SANTA ROSA
Practice Address - State:CA
Practice Address - Zip Code:95407-7318
Practice Address - Country:US
Practice Address - Phone:707-575-5387
Practice Address - Fax:707-570-2647
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-01-26
Last Update Date:2010-01-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA496800053261QD1600X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QD1600XAmbulatory Health Care FacilitiesClinic/CenterDevelopmental Disabilities