Provider Demographics
NPI:1891204400
Name:BLACKWELL, KENNETH (LMT)
Entity Type:Individual
Prefix:
First Name:KENNETH
Middle Name:
Last Name:BLACKWELL
Suffix:
Gender:M
Credentials:LMT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:208 E 23RD AVE
Mailing Address - Street 2:
Mailing Address - City:ANCHORAGE
Mailing Address - State:AK
Mailing Address - Zip Code:99503-2012
Mailing Address - Country:US
Mailing Address - Phone:907-297-8679
Mailing Address - Fax:
Practice Address - Street 1:3310 ARCTIC BLVD STE 102
Practice Address - Street 2:
Practice Address - City:ANCHORAGE
Practice Address - State:AK
Practice Address - Zip Code:99503-4576
Practice Address - Country:US
Practice Address - Phone:907-297-8679
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-09-26
Last Update Date:2018-06-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AK101917225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
AK101917OtherMASSAGE LICENSE