Basic Information
| Provider Information | |||||||||
| NPI: | 1164871489 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | BLAYLOCK | ||||||||
| FirstName: | KACEY | ||||||||
| MiddleName: | DUSTIN | ||||||||
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| Credential: | O.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 360 E MALLARD DR STE 110 | ||||||||
| Address2: | |||||||||
| City: | BOISE | ||||||||
| State: | ID | ||||||||
| PostalCode: | 837063945 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2083368700 | ||||||||
| FaxNumber: | 2084260902 | ||||||||
| Practice Location | |||||||||
| Address1: | 360 E MALLARD DR STE 110 | ||||||||
| Address2: | |||||||||
| City: | BOISE | ||||||||
| State: | ID | ||||||||
| PostalCode: | 837063945 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2083368700 | ||||||||
| FaxNumber: | 2084260902 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/07/2016 | ||||||||
| LastUpdateDate: | 06/16/2021 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 06/16/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 152W00000X | ODP-100370 | ID | Y | Eye and Vision Services Providers | Optometrist |
No ID Information.