Provider Demographics
NPI:1790791580
Name:STAKER, BLAKE KEITH (DC)
Entity Type:Individual
Prefix:
First Name:BLAKE
Middle Name:KEITH
Last Name:STAKER
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 1:1205 UNION STREET
Mailing Address - Street 2:
Mailing Address - City:LANCASTER
Mailing Address - State:PA
Mailing Address - Zip Code:17603
Mailing Address - Country:US
Mailing Address - Phone:563-340-7872
Mailing Address - Fax:
Practice Address - Street 1:46 SOUTH 18TH STREET
Practice Address - Street 2:
Practice Address - City:COLUMBIA
Practice Address - State:PA
Practice Address - Zip Code:17512
Practice Address - Country:US
Practice Address - Phone:717-681-0198
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-31
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PADC009656111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor