MEDICARE: MRS. JANICE KAY BLAZEY MPT

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	225100000X	Physical Therapist	8438	SC

General Provider Information

NPI Number	:	1740252840
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MRS. JANICE KAY BLAZEY MPT

Provider Business Mailing Address
First Line	:	694 REVIVAL ROW
Second Line	:
City	:	FORT MILL
State	:	SC
Zip	:	29708-8959
Country	:	US
Telephone Number	:	757-639-5653
Fax Number	:

Provider Business Practice Location Address
First Line	:	3541 RANDOLPH RD
Second Line	:	SUITE 100
City	:	CHARLOTTE
State	:	NC
Zip	:	28211-1082
Country	:	US
Telephone Number	:	704-323-2520
Fax Number	:	704-323-2501

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

Provider Enumeration Date	:	02/02/2006
Last Update Date	:	02/06/2017

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