Provider Demographics
NPI:1952493991
Name:BLAKE, THOMAS T JR (DC)
Entity Type:Individual
Prefix:MR
First Name:THOMAS
Middle Name:T
Last Name:BLAKE
Suffix:JR
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 1:4715 SUNSET BLVD STE C
Mailing Address - Street 2:
Mailing Address - City:LEXINGTON
Mailing Address - State:SC
Mailing Address - Zip Code:29072-9151
Mailing Address - Country:US
Mailing Address - Phone:803-520-8631
Mailing Address - Fax:803-520-8634
Practice Address - Street 1:4715 SUNSET BLVD STE C
Practice Address - Street 2:
Practice Address - City:LEXINGTON
Practice Address - State:SC
Practice Address - Zip Code:29072-9151
Practice Address - Country:US
Practice Address - Phone:803-520-8631
Practice Address - Fax:803-520-8634
Is Sole Proprietor?:No
Enumeration Date:2006-09-28
Last Update Date:2011-10-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC3261111N00000X
CADC20126111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor