Healthcare Provider Details

I. General information

NPI: 1528488277
Provider Name (Legal Business Name): ROBERT WEBSTER BLAKEWELL PT
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 04/21/2014
Last Update Date: 04/21/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3446 BROWNS VALLEY RD
VACAVILLE CA
95688-9339
US

IV. Provider business mailing address

1200 B GALE WILSON BLVD
FAIRFIELD CA
94533-3552
US

V. Phone/Fax

Practice location:
  • Phone: 707-624-7470
  • Fax:
Mailing address:
  • Phone: 707-624-7470
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License Number16777
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: