Provider Demographics
NPI:1316572365
Name:BLAKELY, KYLE JOSHUA
Entity Type:Individual
Prefix:
First Name:KYLE
Middle Name:JOSHUA
Last Name:BLAKELY
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 1:6036 S GREEN ST APT 2
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60621-2169
Mailing Address - Country:US
Mailing Address - Phone:312-278-7494
Mailing Address - Fax:
Practice Address - Street 1:6036 S GREEN ST APT 2
Practice Address - Street 2:
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60621-2169
Practice Address - Country:US
Practice Address - Phone:312-278-7494
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-03-10
Last Update Date:2020-03-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes343900000XTransportation ServicesNon-emergency Medical Transport (VAN)