Healthcare Provider Details

I. General information

NPI: 1336656263
Provider Name (Legal Business Name): MOSI BLAKE L/ATC
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 12/31/2017
Last Update Date: 04/22/2021
Certification Date: 04/22/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

305 E BRANDON BLVD
BRANDON FL
33511-5222
US

IV. Provider business mailing address

13020 N TELECOM PKWY
TEMPLE TERRACE FL
33637-0925
US

V. Phone/Fax

Practice location:
  • Phone: 813-978-9700
  • Fax: 813-558-6187
Mailing address:
  • Phone: 813-978-9700
  • Fax: 813-558-6187

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2255A2300X
TaxonomyAthletic Trainer
License NumberAL2928
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: