MEDICARE: KEVIN BLANCO

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	2255A2300X	Athletic Trainer	39540533	NC
2	390200000X	Student in an Organized Health Care Education/Training Program	39540533	NC

General Provider Information

NPI Number	:	1104362581
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	KEVIN BLANCO

Provider Business Mailing Address
First Line	:	163 VIRGINIA RD
Second Line	:	PO BOX 935
City	:	MONTREAT
State	:	NC
Zip	:	28757
Country	:	US
Telephone Number	:	704-740-0657
Fax Number	:

Provider Business Practice Location Address
First Line	:	163 VIRGINIA RD
Second Line	:
City	:	MONTREAT
State	:	NC
Zip	:	28757
Country	:	US
Telephone Number	:	704-740-0657
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	01/10/2017
Last Update Date	:	01/10/2017

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