Provider Demographics
NPI:1013414937
Name:BLAYLOCK REHABILITATION, LLC
Entity Type:Organization
Organization Name:BLAYLOCK REHABILITATION, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER/PHYSICAL THERAPIST
Authorized Official - Prefix:
Authorized Official - First Name:AKILAH
Authorized Official - Middle Name:S
Authorized Official - Last Name:BLAYLOCK
Authorized Official - Suffix:
Authorized Official - Credentials:DPT
Authorized Official - Phone:470-241-4010
Mailing Address - Street 1:PO BOX 982
Mailing Address - Street 2:
Mailing Address - City:FAIRBURN
Mailing Address - State:GA
Mailing Address - Zip Code:30213-0982
Mailing Address - Country:US
Mailing Address - Phone:470-241-4010
Mailing Address - Fax:
Practice Address - Street 1:7248 PARKLAND BND
Practice Address - Street 2:
Practice Address - City:FAIRBURN
Practice Address - State:GA
Practice Address - Zip Code:30213-5435
Practice Address - Country:US
Practice Address - Phone:470-241-4010
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2018-04-07
Last Update Date:2018-04-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GAPT009057225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistGroup - Single Specialty