Provider Demographics
NPI:1033876461
Name:BLAKE, MARC B
Entity Type:Individual
Prefix:
First Name:MARC
Middle Name:B
Last Name:BLAKE
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5750 JOHNSTON ST STE 502
Mailing Address - Street 2:
Mailing Address - City:LAFAYETTE
Mailing Address - State:LA
Mailing Address - Zip Code:70503-5334
Mailing Address - Country:US
Mailing Address - Phone:337-417-9200
Mailing Address - Fax:
Practice Address - Street 1:2102 MACARTHUR DR STE C
Practice Address - Street 2:
Practice Address - City:ALEXANDRIA
Practice Address - State:LA
Practice Address - Zip Code:71301-3763
Practice Address - Country:US
Practice Address - Phone:866-550-6849
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-11-19
Last Update Date:2021-11-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes237700000XSpeech, Language and Hearing Service ProvidersHearing Instrument Specialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
LA007076923OtherDRIVERS LICENSE