Healthcare Provider Details

I. General information

NPI: 1699084608
Provider Name (Legal Business Name): KEN BLACKBURN
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 09/26/2010
Last Update Date: 09/26/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

480 GALLETTI WAY
SPARKS NV
89431-5564
US

IV. Provider business mailing address

7491 AMBUSH CT
SPARKS NV
89436-7459
US

V. Phone/Fax

Practice location:
  • Phone: 775-333-0943
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225400000X
TaxonomyRehabilitation Practitioner
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: