Healthcare Provider Details

I. General information

NPI: 1699142703
Provider Name (Legal Business Name): DENNIS RAY BLEVINS JR. DPT
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/24/2015
Last Update Date: 08/24/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

400 DIXIE LEE CENTER RD SUITE A
KIMBALL TN
37347-5672
US

IV. Provider business mailing address

400 DIXIE LEE CENTER RD SUITE A
KIMBALL TN
37347-5672
US

V. Phone/Fax

Practice location:
  • Phone: 423-837-7536
  • Fax: 423-837-7538
Mailing address:
  • Phone: 423-837-7536
  • Fax: 423-837-7538

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License NumberPT003547
License Number StateWV

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: