Provider Demographics
NPI:1750666756
Name:BLAKE RESOURCES LLC
Entity Type:Organization
Organization Name:BLAKE RESOURCES LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRINCIPAL
Authorized Official - Prefix:MS
Authorized Official - First Name:GRACE
Authorized Official - Middle Name:
Authorized Official - Last Name:SMITH
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:704-231-3191
Mailing Address - Street 1:11418 FRANK LITTLE CT
Mailing Address - Street 2:
Mailing Address - City:CHARLOTTE
Mailing Address - State:NC
Mailing Address - Zip Code:28269-2137
Mailing Address - Country:US
Mailing Address - Phone:704-231-3191
Mailing Address - Fax:888-463-6116
Practice Address - Street 1:1000 BAXTER ST
Practice Address - Street 2:
Practice Address - City:CHARLOTTE
Practice Address - State:NC
Practice Address - Zip Code:28204-2859
Practice Address - Country:US
Practice Address - Phone:704-231-3191
Practice Address - Fax:888-463-6116
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-10-21
Last Update Date:2011-10-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251S00000XAgenciesCommunity/Behavioral Health