Provider Demographics
NPI:1942407465
Name:EQUINOX LLC
Entity type:Organization
Organization Name:EQUINOX LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:RICHARD
Authorized Official - Middle Name:J
Authorized Official - Last Name:BLACKBURN
Authorized Official - Suffix:
Authorized Official - Credentials:DO
Authorized Official - Phone:304-868-6000
Mailing Address - Street 1:705 WASHINGTON ST
Mailing Address - Street 2:
Mailing Address - City:RAVENSWOOD
Mailing Address - State:WV
Mailing Address - Zip Code:26164-1729
Mailing Address - Country:US
Mailing Address - Phone:304-868-6000
Mailing Address - Fax:304-868-6002
Practice Address - Street 1:705 WASHINGTON ST
Practice Address - Street 2:
Practice Address - City:RAVENSWOOD
Practice Address - State:WV
Practice Address - Zip Code:26164-1729
Practice Address - Country:US
Practice Address - Phone:304-868-6000
Practice Address - Fax:304-868-6002
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-06-28
Last Update Date:2007-10-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
WV9352581Medicare PIN