Basic Information
| Provider Information | |||||||||
| NPI: | 1578230132 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | BLANCK | ||||||||
| FirstName: | DANIEL | ||||||||
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| Credential: | PT, DPT | ||||||||
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| Mailing Information | |||||||||
| Address1: | 2939 VAUGHNDALE DR | ||||||||
| Address2: | |||||||||
| City: | MACHESNEY PARK | ||||||||
| State: | IL | ||||||||
| PostalCode: | 611157670 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8159799635 | ||||||||
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| Practice Location | |||||||||
| Address1: | 209 9TH ST | ||||||||
| Address2: | |||||||||
| City: | ROCKFORD | ||||||||
| State: | IL | ||||||||
| PostalCode: | 611042235 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7796962750 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 08/23/2021 | ||||||||
| LastUpdateDate: | 08/23/2021 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 08/23/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 225100000X | IL | Y | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Physical Therapist |
No ID Information.