=====================================================
General NPI Number Information
=====================================================
NPI Number | 1821240854
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | BLAKELY PARENT LMT
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 10/22/2008
-----------------------------------------------------
Last Update Date | 10/22/2008
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 107 BAY BRIDGE DR
-----------------------------------------------------
City | GULF BREEZE
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 32561-7428
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 850-291-2393
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 1517 E GONZALEZ ST
-----------------------------------------------------
City | PENSACOLA
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 32501-3448
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 850-291-2393
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 225700000X
-----------------------------------------------------
Taxonomy Name | Massage Therapist
-----------------------------------------------------
License Number | 30010
-----------------------------------------------------
License Number State | FL
-----------------------------------------------------