Provider Demographics
NPI:1871972810
Name:BLANKENSHIP, VINCENT (DPT, ATC)
Entity type:Individual
Prefix:
First Name:VINCENT
Middle Name:
Last Name:BLANKENSHIP
Suffix:
Gender:M
Credentials:DPT, ATC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 877 ONE RODGERS DR.
Mailing Address - Street 2:MILLAN PUSKAR STADIUM
Mailing Address - City:MORGANTOWN
Mailing Address - State:WV
Mailing Address - Zip Code:26507-0877
Mailing Address - Country:US
Mailing Address - Phone:304-293-9542
Mailing Address - Fax:
Practice Address - Street 1:ONE RODGERS DR.
Practice Address - Street 2:MILLAN PUSKAR STADIUM
Practice Address - City:MORGANTOWN
Practice Address - State:WV
Practice Address - Zip Code:26507-0877
Practice Address - Country:US
Practice Address - Phone:304-293-9542
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2015-05-22
Last Update Date:2015-05-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL28536225100000X
WVPT 003354225100000X
WVAT0013602255A2300X
GAAT0016662255A2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
No2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer