Healthcare Provider Details

I. General information

NPI: 1295207371
Provider Name (Legal Business Name): MARY BLOCHBERGER MED, ATC, LAT
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/29/2018
Last Update Date: 12/29/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1432 SOUTHWEST BLVD
JEFFERSON CITY MO
65109-2444
US

IV. Provider business mailing address

12813 BRUSH CREEK RD
RUSSELLVILLE MO
65074-2742
US

V. Phone/Fax

Practice location:
  • Phone: 573-632-5614
  • Fax:
Mailing address:
  • Phone: 573-338-2333
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2255A2300X
TaxonomyAthletic Trainer
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: