Provider Demographics
NPI:1366954802
Name:BLAYLOCK, CHRISTOPHER THOMAS (CCP)
Entity type:Individual
Prefix:
First Name:CHRISTOPHER
Middle Name:THOMAS
Last Name:BLAYLOCK
Suffix:
Gender:M
Credentials:CCP
Other - Prefix:
Other - First Name:CHRISTOPHER
Other - Middle Name:THOMAS
Other - Last Name:BLAYLOCK
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:CCP
Mailing Address - Street 1:1252 N 550 W
Mailing Address - Street 2:
Mailing Address - City:WEST BOUNTIFUL
Mailing Address - State:UT
Mailing Address - Zip Code:84087-1264
Mailing Address - Country:US
Mailing Address - Phone:801-678-0425
Mailing Address - Fax:
Practice Address - Street 1:50 N MEDICAL DR
Practice Address - Street 2:
Practice Address - City:SALT LAKE CITY
Practice Address - State:UT
Practice Address - Zip Code:84132-0001
Practice Address - Country:US
Practice Address - Phone:801-581-2121
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-10-24
Last Update Date:2017-10-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes242T00000XTechnologists, Technicians & Other Technical Service ProvidersPerfusionist