Provider Demographics
NPI:1760122485
Name:SCHOLES, BLAINE ALAN (PTA)
Entity Type:Individual
Prefix:
First Name:BLAINE
Middle Name:ALAN
Last Name:SCHOLES
Suffix:
Gender:M
Credentials:PTA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:400 S STATION RD
Mailing Address - Street 2:
Mailing Address - City:GLEN CARBON
Mailing Address - State:IL
Mailing Address - Zip Code:62034-2743
Mailing Address - Country:US
Mailing Address - Phone:618-288-5014
Mailing Address - Fax:
Practice Address - Street 1:400 S STATION RD
Practice Address - Street 2:
Practice Address - City:GLEN CARBON
Practice Address - State:IL
Practice Address - Zip Code:62034-2743
Practice Address - Country:US
Practice Address - Phone:618-288-5014
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-03-30
Last Update Date:2022-03-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL160.008256225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant