Basic Information
| Provider Information | |||||||||
| NPI: | 1679080386 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | BLANCO | ||||||||
| FirstName: | JOEL | ||||||||
| MiddleName: | |||||||||
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| Credential: | PT | ||||||||
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| OtherLastName: | BLANCO | ||||||||
| OtherFirstName: | JOEL | ||||||||
| OtherMiddleName: | D | ||||||||
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| OtherCredential: | ATC | ||||||||
| OtherLastNameType: | 5 | ||||||||
| Mailing Information | |||||||||
| Address1: | 336 BROAD ST STE 203 | ||||||||
| Address2: | |||||||||
| City: | ROME | ||||||||
| State: | GA | ||||||||
| PostalCode: | 301613006 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4078808438 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 541 N PARK AVE | ||||||||
| Address2: | |||||||||
| City: | APOPKA | ||||||||
| State: | FL | ||||||||
| PostalCode: | 327123654 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4078808438 | ||||||||
| FaxNumber: | 4078809570 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 01/03/2018 | ||||||||
| LastUpdateDate: | 08/27/2020 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 08/27/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 2255A2300X | AL3812 | FL | N | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Specialist/Technologist | Athletic Trainer | 225100000X | PT36067 | FL | Y | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Physical Therapist |
No ID Information.