Provider Demographics
NPI:1699362012
Name:SMITH, BLAKE ALEXANDER (LAT, ATC, MS)
Entity Type:Individual
Prefix:MR
First Name:BLAKE
Middle Name:ALEXANDER
Last Name:SMITH
Suffix:
Gender:M
Credentials:LAT, ATC, MS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:125 S 2ND ST
Mailing Address - Street 2:
Mailing Address - City:ARKANSAS CITY
Mailing Address - State:KS
Mailing Address - Zip Code:67005-2662
Mailing Address - Country:US
Mailing Address - Phone:620-687-1680
Mailing Address - Fax:
Practice Address - Street 1:125 S 2ND ST
Practice Address - Street 2:
Practice Address - City:ARKANSAS CITY
Practice Address - State:KS
Practice Address - Zip Code:67005-2662
Practice Address - Country:US
Practice Address - Phone:620-687-1680
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-12-31
Last Update Date:2020-12-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KS24-011122255A2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic TrainerGroup - Single Specialty