Provider Demographics
NPI:1578238911
Name:BLAKE, LONDONE
Entity Type:Individual
Prefix:
First Name:LONDONE
Middle Name:
Last Name:BLAKE
Suffix:
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 1:25 SEVERANCE CIR APT 204
Mailing Address - Street 2:
Mailing Address - City:CLEVELAND HEIGHTS
Mailing Address - State:OH
Mailing Address - Zip Code:44118-1505
Mailing Address - Country:US
Mailing Address - Phone:216-203-2625
Mailing Address - Fax:
Practice Address - Street 1:25 SEVERANCE CIR APT 204
Practice Address - Street 2:
Practice Address - City:CLEVELAND HEIGHTS
Practice Address - State:OH
Practice Address - Zip Code:44118-1505
Practice Address - Country:US
Practice Address - Phone:216-203-2625
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-08-09
Last Update Date:2021-08-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes374U00000XNursing Service Related ProvidersHome Health Aide