Provider Demographics
NPI:1023620648
Name:MALDONADO, BLANCA ESTELA (OPTICIAN)
Entity type:Individual
Prefix:
First Name:BLANCA
Middle Name:ESTELA
Last Name:MALDONADO
Suffix:
Gender:F
Credentials:OPTICIAN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1661 DAVIDSON ST
Mailing Address - Street 2:
Mailing Address - City:LOMA LINDA
Mailing Address - State:CA
Mailing Address - Zip Code:92354-1708
Mailing Address - Country:US
Mailing Address - Phone:909-261-0483
Mailing Address - Fax:
Practice Address - Street 1:671 E COOLEY DR STE 102
Practice Address - Street 2:
Practice Address - City:COLTON
Practice Address - State:CA
Practice Address - Zip Code:92324-4014
Practice Address - Country:US
Practice Address - Phone:909-261-0483
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-08-17
Last Update Date:2020-08-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CASLD5882156FX1800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes156FX1800XEye and Vision Services ProvidersTechnician/TechnologistOptician