Provider Demographics
NPI:1013205566
Name:MAIN, WILLIAM BLAKE (DC)
Entity Type:Individual
Prefix:DR
First Name:WILLIAM
Middle Name:BLAKE
Last Name:MAIN
Suffix:
Gender:M
Credentials:DC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:820 CHUCK GRAY CT.
Mailing Address - Street 2:
Mailing Address - City:OWENSBORO
Mailing Address - State:KY
Mailing Address - Zip Code:42303-7362
Mailing Address - Country:US
Mailing Address - Phone:270-685-5100
Mailing Address - Fax:270-683-3100
Practice Address - Street 1:820 CHUCK GRAY CT.
Practice Address - Street 2:
Practice Address - City:OWENSBORO
Practice Address - State:KY
Practice Address - Zip Code:42303-7362
Practice Address - Country:US
Practice Address - Phone:270-685-5100
Practice Address - Fax:270-683-3100
Is Sole Proprietor?:No
Enumeration Date:2011-07-19
Last Update Date:2016-05-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY5158111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY7100197940Medicaid
KYK037050OtherMEDICARE