Provider Demographics
NPI:1104362581
Name:BLANCO, KEVIN
Entity Type:Individual
Prefix:
First Name:KEVIN
Middle Name:
Last Name:BLANCO
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:163 VIRGINIA RD
Mailing Address - Street 2:PO BOX 935
Mailing Address - City:MONTREAT
Mailing Address - State:NC
Mailing Address - Zip Code:28757
Mailing Address - Country:US
Mailing Address - Phone:704-740-0657
Mailing Address - Fax:
Practice Address - Street 1:163 VIRGINIA RD
Practice Address - Street 2:
Practice Address - City:MONTREAT
Practice Address - State:NC
Practice Address - Zip Code:28757
Practice Address - Country:US
Practice Address - Phone:704-740-0657
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-01-10
Last Update Date:2017-01-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC395405332255A2300X, 390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program