Healthcare Provider Details

I. General information

NPI: 1043135817
Provider Name (Legal Business Name): BLAZE TREVIS HILL
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/11/2026
Last Update Date: 08/11/2026
Certification Date: 08/11/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

16065 S US HIGHWAY 441
SUMMERFIELD FL
34491-5982
US

IV. Provider business mailing address

4 PINE TRACK PL
OCALA FL
34472-8069
US

V. Phone/Fax

Practice location:
  • Phone: 352-285-0167
  • Fax:
Mailing address:
  • Phone: 352-285-0167
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225700000X
TaxonomyMassage Therapist
License NumberMA109768
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: