MEDICARE: DR. KYMBER MICHELLE BLASCHKE OD

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	152W00000X	Optometrist	9270T	TX

General Provider Information

NPI Number	:	1407379886
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. KYMBER MICHELLE BLASCHKE OD

Provider Business Mailing Address
First Line	:	PO BOX 1054
Second Line	:
City	:	YORKTOWN
State	:	TX
Zip	:	78164-1054
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	4800 S HULEN ST STE 2720
Second Line	:
City	:	FORT WORTH
State	:	TX
Zip	:	76132-1465
Country	:	US
Telephone Number	:	817-346-2186
Fax Number	:	817-370-7902

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

Provider Enumeration Date	:	07/18/2017
Last Update Date	:	03/17/2018

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