Basic Information
| Provider Information | |||||||||
| NPI: | 1306222534 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | BLAZEK | ||||||||
| FirstName: | MARK | ||||||||
| MiddleName: | D | ||||||||
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| Credential: | DPT | ||||||||
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| Mailing Information | |||||||||
| Address1: | 10 WILLIAM POPE DR | ||||||||
| Address2: | SUITE 3 | ||||||||
| City: | BLUFFTON | ||||||||
| State: | SC | ||||||||
| PostalCode: | 299097549 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8437059440 | ||||||||
| FaxNumber: | 8437059445 | ||||||||
| Practice Location | |||||||||
| Address1: | 3250 HARDEN STREET EXT | ||||||||
| Address2: | SUITE 100 | ||||||||
| City: | COLUMBIA | ||||||||
| State: | SC | ||||||||
| PostalCode: | 292036842 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8035096389 | ||||||||
| FaxNumber: | 8035096390 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/11/2015 | ||||||||
| LastUpdateDate: | 08/11/2015 | ||||||||
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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 | 7901 | SC | Y | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Physical Therapist |
No ID Information.