1215988605 NPI number — MARK WILLIAM BLACKLEY PHYSICAL THERAPIST

Table of content: MARK WILLIAM BLACKLEY PHYSICAL THERAPIST (NPI 1215988605)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1215988605 NPI number — MARK WILLIAM BLACKLEY PHYSICAL THERAPIST

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
BLACKLEY
Provider First Name:
MARK
Provider Middle Name:
WILLIAM
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
PHYSICAL THERAPIST
Provider Gender Code:
M

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1215988605
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
07/02/2025
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
1650 COCHRANE CIR, ATTN: CREDENTIALS OFFICE
Provider Second Line Business Mailing Address:
USA MEDDAC, EVANS ARMY COMMUNITY HOSPITAL
Provider Business Mailing Address City Name:
FORT CARSON
Provider Business Mailing Address State Name:
CO
Provider Business Mailing Address Postal Code:
80913-4604
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
719-526-7844
Provider Business Mailing Address Fax Number:
719-526-7984

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
PHYSICAL THERAPY CLINIC
Provider Second Line Business Practice Location Address:
USA MEDDAC, EVANS ARMY COMMUNITY HOSPITAL
Provider Business Practice Location Address City Name:
FORT CARSON
Provider Business Practice Location Address State Name:
CO
Provider Business Practice Location Address Postal Code:
80913-4604
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
719-526-7120
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
05/12/2006

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 2251E1300X , with the licence number:  2788 , registered in the state of CO ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)





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