MEDICARE: BLAKE GERMANN ATC, LAT

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	390200000X	Student in an Organized Health Care Education/Training Program	AL 3753	FL

General Provider Information

NPI Number	:	1770032500
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	BLAKE GERMANN ATC, LAT

Provider Business Mailing Address
First Line	:	3563 PHILLIPS HWY STE 502
Second Line	:
City	:	JACKSONVILLE
State	:	FL
Zip	:	32207-5663
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	4412 BARNES RD
Second Line	:
City	:	JACKSONVILLE
State	:	FL
Zip	:	32207-7469
Country	:	US
Telephone Number	:	904-739-5212
Fax Number	:

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

Provider Enumeration Date	:	09/21/2016
Last Update Date	:	09/21/2016

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