MEDICARE: MR. JOEL BLANCO PT

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	1167790	TX

General Provider Information

NPI Number	:	1942400304
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MR. JOEL BLANCO PT

Provider Business Mailing Address
First Line	:	15800 MIDWAY RD
Second Line	:
City	:	ADDISON
State	:	TX
Zip	:	75001-4259
Country	:	US
Telephone Number	:	972-720-7915
Fax Number	:	972-720-7778

Provider Business Practice Location Address
First Line	:	8267 ELMBROOK
Second Line	:	SUITE 101
City	:	DALLAS
State	:	TX
Zip	:	75247-4030
Country	:	US
Telephone Number	:	214-630-2331
Fax Number	:	214-905-1323

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

Provider Enumeration Date	:	07/23/2007
Last Update Date	:	07/23/2007

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