Provider Demographics
NPI:1083467179
Name:BLAKE, DAVID
Entity Type:Individual
Prefix:
First Name:DAVID
Middle Name:
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 1:5740 W BARN RD APT 2401
Mailing Address - Street 2:
Mailing Address - City:HERRIMAN
Mailing Address - State:UT
Mailing Address - Zip Code:84096-5112
Mailing Address - Country:US
Mailing Address - Phone:801-915-7248
Mailing Address - Fax:
Practice Address - Street 1:2295 S FOOTHILL DR STE 1
Practice Address - Street 2:
Practice Address - City:SALT LAKE CITY
Practice Address - State:UT
Practice Address - Zip Code:84109-4006
Practice Address - Country:US
Practice Address - Phone:801-486-7542
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-04-08
Last Update Date:2024-04-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist