MEDICARE: MR. KYLE MATTHEW BLEVINGS LAT, ATC

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	2000015073
2	2255A2300X	Athletic Trainer	AT 0000001766	TN
3	171M00000X	Case Manager/Care Coordinator		OH

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	2000015073	OTHER		BOARD OF CERTIFICATION (BOC)
2	AT 0000001766	OTHER	TN	STATE OF TENNESSEE DIVISION OF HEALTH RELATED BOARDS

General Provider Information

NPI Number	:	1164874715
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MR. KYLE MATTHEW BLEVINGS LAT, ATC

Provider Business Mailing Address
First Line	:	3012 GLENMORE AVE STE 104
Second Line	:
City	:	CINCINNATI
State	:	OH
Zip	:	45238-2258
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	3012 GLENMORE AVE STE 104
Second Line	:
City	:	CINCINNATI
State	:	OH
Zip	:	45238-2258
Country	:	US
Telephone Number	:	844-584-7284
Fax Number	:

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

Provider Enumeration Date	:	07/07/2016
Last Update Date	:	10/01/2020

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