Healthcare Provider Details

I. General information

NPI: 1215988605
Provider Name (Legal Business Name): MARK WILLIAM BLACKLEY PHYSICAL THERAPIST
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/12/2006
Last Update Date: 07/02/2025
Certification Date: 07/02/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

PHYSICAL THERAPY CLINIC USA MEDDAC, EVANS ARMY COMMUNITY HOSPITAL
FORT CARSON CO
80913-4604
US

IV. Provider business mailing address

1650 COCHRANE CIR, ATTN: CREDENTIALS OFFICE USA MEDDAC, EVANS ARMY COMMUNITY HOSPITAL
FORT CARSON CO
80913-4604
US

V. Phone/Fax

Practice location:
  • Phone: 719-526-7120
  • Fax:
Mailing address:
  • Phone: 719-526-7844
  • Fax: 719-526-7984

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2251E1300X
TaxonomyClinical Electrophysiology Physical Therapist
License Number2788
License Number StateCO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: