Healthcare Provider Details

I. General information

NPI: 1508222340
Provider Name (Legal Business Name): BLANFORD PEDIATRIC THERAPY LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/09/2016
Last Update Date: 01/12/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

704 BLOOMFIELD RD
BARDSTOWN KY
40004-2025
US

IV. Provider business mailing address

704 BLOOMFIELD RD
BARDSTOWN KY
40004-2025
US

V. Phone/Fax

Practice location:
  • Phone: 502-331-5478
  • Fax: 502-348-9825
Mailing address:
  • Phone: 859-797-8223
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License Number
License Number StateKY
# 2
Primary TaxonomyY
Taxonomy Code225XP0200X
TaxonomyPediatric Occupational Therapist
License Number135224
License Number StateKY
# 3
Primary TaxonomyN
Taxonomy Code235Z00000X
TaxonomySpeech-Language Pathologist
License Number140780
License Number StateKY
# 4
Primary TaxonomyN
Taxonomy Code252Y00000X
TaxonomyEarly Intervention Provider Agency
License Number
License Number State

VIII. Authorized Official

Name: MR. LANCE PATRICK BLANFORD
Title or Position: OWNER
Credential: M.ED.
Phone: 859-797-8223