Basic Information
| Provider Information | |||||||||
| NPI: | 1215988605 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | BLACKLEY | ||||||||
| FirstName: | MARK | ||||||||
| MiddleName: | WILLIAM | ||||||||
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| Credential: | PHYSICAL THERAPIST | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1650 COCHRANE CIR, ATTN: CREDENTIALS OFFICE | ||||||||
| Address2: | USA MEDDAC, EVANS ARMY COMMUNITY HOSPITAL | ||||||||
| City: | FORT CARSON | ||||||||
| State: | CO | ||||||||
| PostalCode: | 809134604 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7195267844 | ||||||||
| FaxNumber: | 7195267984 | ||||||||
| Practice Location | |||||||||
| Address1: | PHYSICAL THERAPY CLINIC | ||||||||
| Address2: | USA MEDDAC, EVANS ARMY COMMUNITY HOSPITAL | ||||||||
| City: | FORT CARSON | ||||||||
| State: | CO | ||||||||
| PostalCode: | 809134604 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7195267120 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 05/12/2006 | ||||||||
| LastUpdateDate: | 03/31/2021 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 03/31/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 2251E1300X | 2788 | CO | Y | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Physical Therapist | Electrophysiology, Clinical |
No ID Information.