Provider Demographics
NPI:1497198311
Name:BLANCHARD, KEVIN LAYNE (PT)
Entity Type:Individual
Prefix:
First Name:KEVIN
Middle Name:LAYNE
Last Name:BLANCHARD
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 1:5957 FASHION POINT DR
Mailing Address - Street 2:STE. 102
Mailing Address - City:SOUTH OGDEN
Mailing Address - State:UT
Mailing Address - Zip Code:84403-5180
Mailing Address - Country:US
Mailing Address - Phone:801-827-0200
Mailing Address - Fax:
Practice Address - Street 1:5957 FASHION POINT DR
Practice Address - Street 2:STE. 102
Practice Address - City:SOUTH OGDEN
Practice Address - State:UT
Practice Address - Zip Code:84403-5180
Practice Address - Country:US
Practice Address - Phone:801-827-0200
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2013-04-10
Last Update Date:2013-04-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT7986778-24012251X0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2251X0800XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistOrthopedic