Healthcare Provider Details

I. General information

NPI: 1154164309
Provider Name (Legal Business Name): ZACHARY ALAN BLAYDES
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/17/2024
Last Update Date: 08/14/2024
Certification Date: 08/14/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3401 YORKSHIRE MEDICAL PARK
LEXINGTON KY
40509-2513
US

IV. Provider business mailing address

3480 YORKSHIRE MEDICAL PARK
LEXINGTON KY
40509-1886
US

V. Phone/Fax

Practice location:
  • Phone: 859-263-5140
  • Fax: 859-263-5141
Mailing address:
  • Phone: 859-263-5140
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code2251S0007X
TaxonomySports Physical Therapist
License Number2023032337
License Number StateMO
# 2
Primary TaxonomyY
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License Number009165
License Number StateKY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: