Provider Demographics
NPI:1689321549
Name:EDMONSON, BLAKE JOSEPH (DC)
Entity Type:Individual
Prefix:
First Name:BLAKE
Middle Name:JOSEPH
Last Name:EDMONSON
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 1:1813 W CALDWELL AVE STE B
Mailing Address - Street 2:
Mailing Address - City:VISALIA
Mailing Address - State:CA
Mailing Address - Zip Code:93277-8003
Mailing Address - Country:US
Mailing Address - Phone:559-625-1100
Mailing Address - Fax:559-625-1110
Practice Address - Street 1:1813 W CALDWELL AVE STE B
Practice Address - Street 2:
Practice Address - City:VISALIA
Practice Address - State:CA
Practice Address - Zip Code:93277-8003
Practice Address - Country:US
Practice Address - Phone:559-625-1100
Practice Address - Fax:559-625-1110
Is Sole Proprietor?:Yes
Enumeration Date:2022-03-09
Last Update Date:2022-06-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CADC36359111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111N00000XChiropractic ProvidersChiropractorGroup - Single Specialty