Healthcare Provider Details

I. General information

NPI: 1225737869
Provider Name (Legal Business Name): THOMAS GERALD BLAKESLEE ATC, LAT
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/02/2023
Last Update Date: 03/02/2023
Certification Date: 02/28/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1800 CAMPUS CENTER DR HPER WEST
SALT LAKE CITY UT
84112
US

IV. Provider business mailing address

325 S ORCHARD DR APT D309
NORTH SALT LAKE UT
84054-1873
US

V. Phone/Fax

Practice location:
  • Phone: 302-220-1247
  • Fax:
Mailing address:
  • Phone: 302-220-1247
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2255A2300X
TaxonomyAthletic Trainer
License Number12937807-4810
License Number StateUT

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: