Individual
BRENTLEY KYLE BLACKMON
Active
Sole proprietor
No
Provider details
NPI number
Gender
Man
Credential
PTA
Contact information
Practice address
401 OWEN LN, WACO, TX 76710-5599
(254) 772-8900
Mailing address
401 OWEN LN, WACO, TX 76710-5599
(254) 772-8900
Taxonomy
Speciality
Code
Description
License number
State
225200000X
Physical Therapy Assistant
Primary
2108097
TX
Other
Enumeration date
09/03/2018
Last updated
09/03/2018
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