Provider Demographics
NPI:1558909440
Name:ROYLANCE, BLAKE BERT (DC)
Entity Type:Individual
Prefix:
First Name:BLAKE
Middle Name:BERT
Last Name:ROYLANCE
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 1:1342 S PIONEER WAY
Mailing Address - Street 2:
Mailing Address - City:MOSES LAKE
Mailing Address - State:WA
Mailing Address - Zip Code:98837-2410
Mailing Address - Country:US
Mailing Address - Phone:509-855-6482
Mailing Address - Fax:
Practice Address - Street 1:1342 S PIONEER WAY
Practice Address - Street 2:
Practice Address - City:MOSES LAKE
Practice Address - State:WA
Practice Address - Zip Code:98837-2410
Practice Address - Country:US
Practice Address - Phone:509-855-6482
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-12-11
Last Update Date:2022-07-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WACH61024794111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
WACH61024794OtherINSURANCE