Provider Demographics
NPI:1730415613
Name:BLACKSTONE, STEVEN LANCE
Entity type:Individual
Prefix:
First Name:STEVEN
Middle Name:LANCE
Last Name:BLACKSTONE
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 1:303 CROWN CT
Mailing Address - Street 2:
Mailing Address - City:CONVERSE
Mailing Address - State:TX
Mailing Address - Zip Code:78109-1828
Mailing Address - Country:US
Mailing Address - Phone:512-351-0021
Mailing Address - Fax:
Practice Address - Street 1:12402 TOEPPERWEIN RD
Practice Address - Street 2:
Practice Address - City:LIVE OAK
Practice Address - State:TX
Practice Address - Zip Code:78233-3230
Practice Address - Country:US
Practice Address - Phone:512-351-0021
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2009-10-27
Last Update Date:2011-10-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX3734174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist