Provider Demographics
NPI:1497889422
Name:BOWERS, BLAKE RAYMOND (ATC)
Entity Type:Individual
Prefix:
First Name:BLAKE
Middle Name:RAYMOND
Last Name:BOWERS
Suffix:
Gender:M
Credentials:ATC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2770 32ND ST
Mailing Address - Street 2:
Mailing Address - City:COOS BAY
Mailing Address - State:OR
Mailing Address - Zip Code:97420-3541
Mailing Address - Country:US
Mailing Address - Phone:541-888-7430
Mailing Address - Fax:541-888-7196
Practice Address - Street 1:1988 NEWMARK AVE
Practice Address - Street 2:
Practice Address - City:COOS BAY
Practice Address - State:OR
Practice Address - Zip Code:97420-2911
Practice Address - Country:US
Practice Address - Phone:541-888-7430
Practice Address - Fax:541-888-7196
Is Sole Proprietor?:Yes
Enumeration Date:2007-03-14
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORAT-AT-3677952255A2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer
Provider Identifiers
StateIdentifier IDID TypeIssuer
ORAT-AT-367795OtherOREGON HEALTH LICENSING O