Provider Demographics
NPI:1285029389
Name:BLAKE, ROBERT DEMAREST JR
Entity Type:Individual
Prefix:
First Name:ROBERT
Middle Name:DEMAREST
Last Name:BLAKE
Suffix:JR
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 1:11242 MILLS MILLS RD
Mailing Address - Street 2:
Mailing Address - City:FILLMORE
Mailing Address - State:NY
Mailing Address - Zip Code:14735-8622
Mailing Address - Country:US
Mailing Address - Phone:214-223-1567
Mailing Address - Fax:
Practice Address - Street 1:11242 MILLS MILLS RD
Practice Address - Street 2:
Practice Address - City:FILLMORE
Practice Address - State:NY
Practice Address - Zip Code:14735-8622
Practice Address - Country:US
Practice Address - Phone:214-223-1567
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2015-04-06
Last Update Date:2015-04-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY251326-1164W00000X, 311ZA0620X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164W00000XNursing Service ProvidersLicensed Practical Nurse
No311ZA0620XNursing & Custodial Care FacilitiesCustodial Care FacilityAdult Care Home