Provider Demographics
NPI:1164871489
Name:BLAYLOCK, KACEY DUSTIN (OD)
Entity Type:Individual
Prefix:
First Name:KACEY
Middle Name:DUSTIN
Last Name:BLAYLOCK
Suffix:
Gender:M
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:360 E MALLARD DR STE 110
Mailing Address - Street 2:
Mailing Address - City:BOISE
Mailing Address - State:ID
Mailing Address - Zip Code:83706-3945
Mailing Address - Country:US
Mailing Address - Phone:208-336-8700
Mailing Address - Fax:208-426-0902
Practice Address - Street 1:360 E MALLARD DR STE 110
Practice Address - Street 2:
Practice Address - City:BOISE
Practice Address - State:ID
Practice Address - Zip Code:83706-3945
Practice Address - Country:US
Practice Address - Phone:208-336-8700
Practice Address - Fax:208-426-0902
Is Sole Proprietor?:No
Enumeration Date:2016-06-07
Last Update Date:2021-06-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDODP-100370152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist