Provider Demographics
NPI:1194876383
Name:BLASKE, KEVIN (ATC)
Entity type:Individual
Prefix:
First Name:KEVIN
Middle Name:
Last Name:BLASKE
Suffix:
Gender:M
Credentials:ATC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5821 SAN AMARO DR
Mailing Address - Street 2:RM 121
Mailing Address - City:CORAL GABLES
Mailing Address - State:FL
Mailing Address - Zip Code:33146-2402
Mailing Address - Country:US
Mailing Address - Phone:305-284-4131
Mailing Address - Fax:
Practice Address - Street 1:5821 SAN AMARO DR
Practice Address - Street 2:RM 121
Practice Address - City:CORAL GABLES
Practice Address - State:FL
Practice Address - Zip Code:33146-2402
Practice Address - Country:US
Practice Address - Phone:305-284-4131
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-01-15
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLAL 1095390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program