Healthcare Provider Details

I. General information

NPI: 1053486811
Provider Name (Legal Business Name): TAMALA BLEVINS
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 11/21/2006
Last Update Date: 06/03/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4041 SMITHFIELD TRL
ELLENWOOD GA
30294-1655
US

IV. Provider business mailing address

4041 SMITHFIELD TRL
ELLENWOOD GA
30294-1655
US

V. Phone/Fax

Practice location:
  • Phone: 404-520-2675
  • Fax:
Mailing address:
  • Phone: 404-520-2675
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License NumberPT007951
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: