Provider Demographics
NPI:1881229953
Name:BLAKE, KYLE
Entity Type:Individual
Prefix:
First Name:KYLE
Middle Name:
Last Name:BLAKE
Suffix:
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 1:38612 ALLEN RD S
Mailing Address - Street 2:
Mailing Address - City:ROY
Mailing Address - State:WA
Mailing Address - Zip Code:98580-9129
Mailing Address - Country:US
Mailing Address - Phone:253-455-1479
Mailing Address - Fax:
Practice Address - Street 1:503 1ST ST S STE 4
Practice Address - Street 2:
Practice Address - City:YELM
Practice Address - State:WA
Practice Address - Zip Code:98597-7634
Practice Address - Country:US
Practice Address - Phone:360-400-5625
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-03-09
Last Update Date:2020-03-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAAC60902550171100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171100000XOther Service ProvidersAcupuncturist