Basic Information
| Provider Information | |||||||||
| NPI: | 1841779998 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | MIGLIN | ||||||||
| FirstName: | BLAKE | ||||||||
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| Credential: | PT, DPT, OCS, CSCS | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 2650 | ||||||||
| Address2: | |||||||||
| City: | COPPELL | ||||||||
| State: | TX | ||||||||
| PostalCode: | 750198607 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9727242400 | ||||||||
| FaxNumber: | 9727242495 | ||||||||
| Practice Location | |||||||||
| Address1: | 4364 HERITAGE TRACE PKWY STE 108 | ||||||||
| Address2: | |||||||||
| City: | FORT WORTH | ||||||||
| State: | TX | ||||||||
| PostalCode: | 762449125 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8173791400 | ||||||||
| FaxNumber: | 8173791404 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/09/2018 | ||||||||
| LastUpdateDate: | 08/29/2022 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 08/29/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 225100000X | 1308356 | TX | Y | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Physical Therapist |
No ID Information.