Provider Demographics
NPI:1104961697
Name:BLANCHARD, DAVID (MPT)
Entity type:Individual
Prefix:
First Name:DAVID
Middle Name:
Last Name:BLANCHARD
Suffix:
Gender:M
Credentials:MPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 2637
Mailing Address - Street 2:
Mailing Address - City:EDWARDS
Mailing Address - State:CO
Mailing Address - Zip Code:81632-2637
Mailing Address - Country:US
Mailing Address - Phone:970-926-4600
Mailing Address - Fax:
Practice Address - Street 1:105 EDWARDS VILLAGE BLVD
Practice Address - Street 2:A-203
Practice Address - City:EDWARDS
Practice Address - State:CO
Practice Address - Zip Code:81632-9914
Practice Address - Country:US
Practice Address - Phone:979-926-4600
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-02-21
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO91772251X0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2251X0800XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistOrthopedic
Provider Identifiers
StateIdentifier IDID TypeIssuer
CO804969Medicare ID - Type Unspecified