Provider Demographics
NPI:1659049419
Name:BLAKE, CORTEZ SANTINO SR
Entity Type:Individual
Prefix:
First Name:CORTEZ
Middle Name:SANTINO
Last Name:BLAKE
Suffix:SR
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 1:19439 TRINITY ST
Mailing Address - Street 2:
Mailing Address - City:DETROIT
Mailing Address - State:MI
Mailing Address - Zip Code:48219-1944
Mailing Address - Country:US
Mailing Address - Phone:313-677-8559
Mailing Address - Fax:
Practice Address - Street 1:19439 TRINITY ST
Practice Address - Street 2:
Practice Address - City:DETROIT
Practice Address - State:MI
Practice Address - Zip Code:48219-1944
Practice Address - Country:US
Practice Address - Phone:313-677-8559
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-09-05
Last Update Date:2021-09-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes172A00000XOther Service ProvidersDriver