Provider Demographics
NPI:1619971207
Name:BLECKLEY, TONY (PT)
Entity Type:Individual
Prefix:
First Name:TONY
Middle Name:
Last Name:BLECKLEY
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:PO BOX 9
Mailing Address - Street 2:
Mailing Address - City:KINGSPORT
Mailing Address - State:TN
Mailing Address - Zip Code:37662-0009
Mailing Address - Country:US
Mailing Address - Phone:423-857-2066
Mailing Address - Fax:423-857-2070
Practice Address - Street 1:105 W STONE DR
Practice Address - Street 2:1D
Practice Address - City:KINGSPORT
Practice Address - State:TN
Practice Address - Zip Code:37660-3256
Practice Address - Country:US
Practice Address - Phone:423-578-1560
Practice Address - Fax:423-392-7055
Is Sole Proprietor?:No
Enumeration Date:2005-06-10
Last Update Date:2009-09-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TNPT 4928225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
TN3658782Medicaid
0281780001Medicare PIN
TN103I086169Medicare UPIN
TNP00100401Medicare PIN
TNCA5023Medicare PIN
TN3658782Medicare ID - Type Unspecified
0281780003Medicare PIN