MEDICARE: BLACKETER ENTERPRISES, INC

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	261QP2000X	Physical Therapy Clinic/Center

General Provider Information

NPI Number	:	1295046050
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	BLACKETER ENTERPRISES, INC

Provider Business Mailing Address
First Line	:	6033 W INTERSTATE 20
Second Line	:
City	:	ARLINGTON
State	:	TX
Zip	:	76017-1042
Country	:	US
Telephone Number	:	817-483-1746
Fax Number	:	817-483-5874

Provider Business Practice Location Address
First Line	:	6033 W INTERSTATE 20
Second Line	:
City	:	ARLINGTON
State	:	TX
Zip	:	76017-1042
Country	:	US
Telephone Number	:	817-483-1746
Fax Number	:	817-483-5874

Authorized Official
Title or Position	:	PRESIDENT
Name	:	JODI MARIE BLACKETER
Credential	:	PT
Telephone Number	:	817-483-1746

Provider Enumeration Date	:	06/27/2010
Last Update Date	:	10/23/2020

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