Provider Demographics
NPI:1073399044
Name:BLAILOCK, KACI
Entity type:Individual
Prefix:
First Name:KACI
Middle Name:
Last Name:BLAILOCK
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:670R MASSACHUSETTS AVE
Mailing Address - Street 2:
Mailing Address - City:ARLINGTON
Mailing Address - State:MA
Mailing Address - Zip Code:02476-5003
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:670R MASSACHUSETTS AVE
Practice Address - Street 2:
Practice Address - City:ARLINGTON
Practice Address - State:MA
Practice Address - Zip Code:02476-5003
Practice Address - Country:US
Practice Address - Phone:781-316-3255
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-09-06
Last Update Date:2023-09-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program