MEDICARE: MR. BRENDEN M BLASCHKE DPT

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	225100000X	Physical Therapist	6846	SC

General Provider Information

NPI Number	:	1144570425
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MR. BRENDEN M BLASCHKE DPT

Provider Business Mailing Address
First Line	:	1413 HIGHWAY 17 N
Second Line	:	SUITE A
City	:	SURFSIDE BEACH
State	:	SC
Zip	:	29575-6012
Country	:	US
Telephone Number	:	843-238-9542
Fax Number	:

Provider Business Practice Location Address
First Line	:	1413 HIGHWAY 17 N
Second Line	:	SUITE A
City	:	SURFSIDE BEACH
State	:	SC
Zip	:	29575-6012
Country	:	US
Telephone Number	:	843-238-9542
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	09/14/2012
Last Update Date	:	09/14/2012

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