Provider Demographics
NPI:1922729094
Name:BLAKE, MICHAEL LEEROY
Entity Type:Individual
Prefix:
First Name:MICHAEL
Middle Name:LEEROY
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 1:27 BOULDER RD
Mailing Address - Street 2:
Mailing Address - City:GLENDALE
Mailing Address - State:WV
Mailing Address - Zip Code:26038
Mailing Address - Country:US
Mailing Address - Phone:304-650-1797
Mailing Address - Fax:
Practice Address - Street 1:27 BOULDER RD
Practice Address - Street 2:
Practice Address - City:GLENDALE
Practice Address - State:WV
Practice Address - Zip Code:26038
Practice Address - Country:US
Practice Address - Phone:304-650-1797
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-09-07
Last Update Date:2022-09-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3747P1801XNursing Service Related ProvidersTechnicianPersonal Care Attendant
Provider Identifiers
StateIdentifier IDID TypeIssuer
WV1356607394Medicaid
WV125553494Medicaid
WV1821206228Medicaid