Basic Information
| Provider Information | |||||||||
| NPI: | 1023533825 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | BLASER | ||||||||
| FirstName: | JEREMIAH | ||||||||
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| Credential: | PT, DPT | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1686 HENRY LUCKOW LN | ||||||||
| Address2: | |||||||||
| City: | BELVIDERE | ||||||||
| State: | IL | ||||||||
| PostalCode: | 610081705 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8155474777 | ||||||||
| FaxNumber: | 8155471024 | ||||||||
| Practice Location | |||||||||
| Address1: | 1686 HENRY LUCKOW LN | ||||||||
| Address2: | |||||||||
| City: | BELVIDERE | ||||||||
| State: | IL | ||||||||
| PostalCode: | 610081705 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8155474777 | ||||||||
| FaxNumber: | 8155471024 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/14/2017 | ||||||||
| LastUpdateDate: | 07/21/2022 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 225100000X | 070.023017 | IL | Y | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Physical Therapist |
No ID Information.