Individual
DERICK BLACKSON
Active
Sole proprietor
Yes
Provider details
NPI number
Gender
Man
Contact information
Practice address
3674 N RANCHO DR, 101, LAS VEGAS, NV 89130-3110
(702) 396-2988
(510) 281-6883
Mailing address
1034 10TH ST, OAKLAND, CA 94607-2720
(702) 396-2988
(510) 281-6883
Taxonomy
Speciality
Code
Description
License number
State
225400000X
Rehabilitation Practitioner
Primary
—
—
Other
Other identifiers
Code
Description
Identifier
Issuer
State
05
—
1114270832
—
NV
Enumeration date
06/16/2014
Last updated
06/16/2014
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