MEDICARE: NIKEYLA BLAKENEY

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	320700000X	Physical Disabilities Residential Treatment Facility	320700000X	MI

General Provider Information

NPI Number	:	1306390737
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	NIKEYLA BLAKENEY

Provider Business Mailing Address
First Line	:	15384 FREELAND ST
Second Line	:
City	:	DETROIT
State	:	MI
Zip	:	48227-2911
Country	:	US
Telephone Number	:	313-758-9151
Fax Number	:

Provider Business Practice Location Address
First Line	:	15384 FREELAND ST
Second Line	:
City	:	DETROIT
State	:	MI
Zip	:	48227-2911
Country	:	US
Telephone Number	:	313-758-9151
Fax Number	:

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

Provider Enumeration Date	:	08/15/2016
Last Update Date	:	08/15/2016

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Directions to “ NIKEYLA BLAKENEY ” Practice Location

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