Healthcare Provider Details

I. General information

NPI: 1487769352
Provider Name (Legal Business Name): GARY LEON BLACKBURN M.S.P.T.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/20/2006
Last Update Date: 04/29/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1055 TIERRA DEL REY SUITE C
CHULA VISTA CA
91910-7875
US

IV. Provider business mailing address

1055 TIERRA DEL REY SUITE C
CHULA VISTA CA
91910-7875
US

V. Phone/Fax

Practice location:
  • Phone: 619-656-5102
  • Fax: 619-656-5143
Mailing address:
  • Phone: 619-656-5102
  • Fax: 619-656-5143

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License Number28897
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: