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General NPI Number Information
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NPI Number | 1588370555
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Entity Type | Individual
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Provider Name | BLAKE FUNG RODMAN
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Gender | Male
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Dates
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Enumeration Date | 01/24/2023
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Last Update Date | 06/08/2025
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Provider Practice Location Address
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Address Line | 2170 SOUTH AVE
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City | SOUTH LAKE TAHOE
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State | CA
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Zip | 96150-7026
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Country | US
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Telephone | 530-539-6600
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Fax |
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Provider Business Mailing Address
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Address Line | 618 E COUGAR RIDGE RD
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City | DRAPER
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State | UT
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Zip | 84020-7825
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Country | US
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Telephone |
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Fax |
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 2255A2300X
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Taxonomy Name | Athletic Trainer
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License Number |
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License Number State |
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