Healthcare Provider Details

I. General information

NPI: 1669872594
Provider Name (Legal Business Name): BLAKE POLLEMA ATC
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/28/2014
Last Update Date: 08/07/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1337 GRAY WOLF CIR
PUEBLO CO
81001-4932
US

IV. Provider business mailing address

34382 COUNTY ROAD 89
BROWERVILLE MN
56438
US

V. Phone/Fax

Practice location:
  • Phone: 320-241-2514
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2255A2300X
TaxonomyAthletic Trainer
License Number2000017573
License Number StateND

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: