Provider Demographics
NPI:1346761871
Name:BARRY, BLAKE (DC)
Entity Type:Individual
Prefix:
First Name:BLAKE
Middle Name:
Last Name:BARRY
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 1:19009 MARCY ST APT 105
Mailing Address - Street 2:
Mailing Address - City:ELKHORN
Mailing Address - State:NE
Mailing Address - Zip Code:68022-4529
Mailing Address - Country:US
Mailing Address - Phone:402-646-5588
Mailing Address - Fax:
Practice Address - Street 1:15615 PACIFIC ST STE 106
Practice Address - Street 2:
Practice Address - City:OMAHA
Practice Address - State:NE
Practice Address - Zip Code:68118-2187
Practice Address - Country:US
Practice Address - Phone:402-933-4447
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-07-06
Last Update Date:2017-07-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NE1942111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor