Healthcare Provider Details

I. General information

NPI: 1497689673
Provider Name (Legal Business Name): KEITH LESLIE BLANKENSHIP PT
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/11/2026
Last Update Date: 06/11/2026
Certification Date: 06/11/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3040 RIVERSIDE DR STE C5
MACON GA
31210-0406
US

IV. Provider business mailing address

137 OLD RIDGE RD
MACON GA
31211-6330
US

V. Phone/Fax

Practice location:
  • Phone: 478-475-9393
  • Fax: 478-475-9353
Mailing address:
  • Phone: 478-361-9689
  • Fax: 478-475-9353

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License NumberPT001629
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: