Provider Demographics
NPI:1871666990
Name:BLAKE CHIROPRACTIC & REHAB CLINIC INC
Entity Type:Organization
Organization Name:BLAKE CHIROPRACTIC & REHAB CLINIC INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DOCTOR
Authorized Official - Prefix:DR
Authorized Official - First Name:ROBERT
Authorized Official - Middle Name:O
Authorized Official - Last Name:BLAKE
Authorized Official - Suffix:
Authorized Official - Credentials:DC
Authorized Official - Phone:717-657-2561
Mailing Address - Street 1:275 S HOUCKS RD
Mailing Address - Street 2:
Mailing Address - City:HARRISBURG
Mailing Address - State:PA
Mailing Address - Zip Code:17109-2907
Mailing Address - Country:US
Mailing Address - Phone:717-657-2561
Mailing Address - Fax:717-657-8217
Practice Address - Street 1:275 S HOUCKS RD
Practice Address - Street 2:
Practice Address - City:HARRISBURG
Practice Address - State:PA
Practice Address - Zip Code:17109-2907
Practice Address - Country:US
Practice Address - Phone:717-657-2561
Practice Address - Fax:717-657-8217
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-11-16
Last Update Date:2012-06-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAPA0002487111NR0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111NR0400XChiropractic ProvidersChiropractorRehabilitationGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
PABL1840042OtherBLUE SHIELD
PA3000116OtherKEYSTONE
PA02520900OtherCAPITOL BLUE CROSS
PA0937995Medicaid
PABL90285Medicare UPIN