Healthcare Provider Details

I. General information

NPI: 1306229281
Provider Name (Legal Business Name): SPENCER BLEVINS AT
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/09/2015
Last Update Date: 06/07/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

7025 STATE ROUTE 61 N
SHELBY OH
44875
US

IV. Provider business mailing address

7025 STATE ROUTE 61 N
SHELBY OH
44875-9590
US

V. Phone/Fax

Practice location:
  • Phone: 419-512-7795
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number StateOH
# 2
Primary TaxonomyY
Taxonomy Code2255A2300X
TaxonomyAthletic Trainer
License NumberAT005595
License Number StateOH

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: