Provider Demographics
NPI:1467045484
Name:BLACKFORD, TRE ALAN (PT)
Entity Type:Individual
Prefix:
First Name:TRE
Middle Name:ALAN
Last Name:BLACKFORD
Suffix:
Gender:M
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:9816 LAGUNA DR
Mailing Address - Street 2:
Mailing Address - City:JOHNSTON
Mailing Address - State:IA
Mailing Address - Zip Code:50131-2998
Mailing Address - Country:US
Mailing Address - Phone:641-751-0027
Mailing Address - Fax:
Practice Address - Street 1:701 RIVERVIEW ST
Practice Address - Street 2:
Practice Address - City:DES MOINES
Practice Address - State:IA
Practice Address - Zip Code:50316-2343
Practice Address - Country:US
Practice Address - Phone:515-266-1106
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-02-19
Last Update Date:2021-02-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IA101467225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist