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Organization
MENDO LAKE UROLOGIC MEDICAL GROUP, INC
Active
Organization
MENDO LAKE UROLOGIC MEDICAL GROUP, INC
Active
Other names
Mendo Lake Urology
Organization subpart
No
Provider details
NPI number
Authorized official
DR. ROBERT EARL BLACKWELDER MD (OWNER)
(707) 462-1928
Entity
Organization
Contact information
Practice address
246 HOSPITAL DR, UKIAH, CA 95482-4533
(707) 462-1928
(707) 462-8642
Mailing address
246 HOSPITAL DR, UKIAH, CA 95482-4533
(707) 462-1928
(707) 462-8642
Taxonomy
Speciality
Code
Description
License number
State
174400000X
Specialist
Primary
A24853
CA
Other
Other identifiers
Code
Description
Identifier
Issuer
State
05
—
ZZZ74887Z
—
CA
Enumeration date
07/07/2006
Last updated
07/18/2007
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