Provider Demographics
NPI:1558027540
Name:BLOXHAM, CAMILLE R (MASSAGE THERAPIST)
Entity Type:Individual
Prefix:
First Name:CAMILLE
Middle Name:R
Last Name:BLOXHAM
Suffix:
Gender:F
Credentials:MASSAGE THERAPIST
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2450 SANDY LN
Mailing Address - Street 2:
Mailing Address - City:AMERICAN FALLS
Mailing Address - State:ID
Mailing Address - Zip Code:83211-5218
Mailing Address - Country:US
Mailing Address - Phone:208-339-6868
Mailing Address - Fax:
Practice Address - Street 1:151 N 4TH AVE
Practice Address - Street 2:
Practice Address - City:POCATELLO
Practice Address - State:ID
Practice Address - Zip Code:83201-6300
Practice Address - Country:US
Practice Address - Phone:208-637-2225
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-11-13
Last Update Date:2021-11-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDMASG-1788225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist