Provider Demographics
NPI:1174013817
Name:BLAKE, SOPHIA (LAC)
Entity Type:Individual
Prefix:
First Name:SOPHIA
Middle Name:
Last Name:BLAKE
Suffix:
Gender:F
Credentials:LAC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2940 W FLORIDA AVE STE B
Mailing Address - Street 2:
Mailing Address - City:HEMET
Mailing Address - State:CA
Mailing Address - Zip Code:92545-3655
Mailing Address - Country:US
Mailing Address - Phone:951-391-3714
Mailing Address - Fax:
Practice Address - Street 1:2940 W FLORIDA AVE STE B
Practice Address - Street 2:
Practice Address - City:HEMET
Practice Address - State:CA
Practice Address - Zip Code:92545-3655
Practice Address - Country:US
Practice Address - Phone:951-391-3714
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-05-17
Last Update Date:2019-12-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAAC16446171100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171100000XOther Service ProvidersAcupuncturist