Provider Demographics
NPI:1114219664
Name:WU, BLAKE K (DC)
Entity Type:Individual
Prefix:MR
First Name:BLAKE
Middle Name:K
Last Name:WU
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 1:4302 W LOVERS LN
Mailing Address - Street 2:
Mailing Address - City:DALLAS
Mailing Address - State:TX
Mailing Address - Zip Code:75209-2804
Mailing Address - Country:US
Mailing Address - Phone:214-862-1469
Mailing Address - Fax:855-950-0085
Practice Address - Street 1:4302 W LOVERS LN
Practice Address - Street 2:
Practice Address - City:DALLAS
Practice Address - State:TX
Practice Address - Zip Code:75209-2804
Practice Address - Country:US
Practice Address - Phone:214-862-1469
Practice Address - Fax:855-950-0085
Is Sole Proprietor?:Yes
Enumeration Date:2011-05-03
Last Update Date:2020-02-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX11670111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor