MEDICARE: KELLI BLUMBERG

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		CA

General Provider Information

NPI Number	:	1639763204
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	KELLI BLUMBERG

Provider Business Mailing Address
First Line	:	3700 COLDWATER CANYON AVE
Second Line	:
City	:	STUDIO CITY
State	:	CA
Zip	:	91604-2301
Country	:	US
Telephone Number	:	818-487-6689
Fax Number	:

Provider Business Practice Location Address
First Line	:	3700 COLDWATER CANYON AVE
Second Line	:
City	:	STUDIO CITY
State	:	CA
Zip	:	91604-2301
Country	:	US
Telephone Number	:	818-487-6689
Fax Number	:

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

Provider Enumeration Date	:	02/24/2021
Last Update Date	:	02/24/2021

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Directions to “ KELLI BLUMBERG ” Practice Location

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