Provider Demographics
NPI:1659444941
Name:BLANTON, BOBBY C
Entity Type:Individual
Prefix:
First Name:BOBBY
Middle Name:C
Last Name:BLANTON
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 1:2312 S DIXON RD
Mailing Address - Street 2:SUITE 250
Mailing Address - City:KOKOMO
Mailing Address - State:IN
Mailing Address - Zip Code:46902-6401
Mailing Address - Country:US
Mailing Address - Phone:765-455-2122
Mailing Address - Fax:765-453-6643
Practice Address - Street 1:2312 S DIXON RD
Practice Address - Street 2:SUITE 250
Practice Address - City:KOKOMO
Practice Address - State:IN
Practice Address - Zip Code:46902-6401
Practice Address - Country:US
Practice Address - Phone:765-455-2122
Practice Address - Fax:765-453-6643
Is Sole Proprietor?:No
Enumeration Date:2006-11-16
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN31003468A225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist