Provider Demographics
NPI:1013075746
Name:BLAKE, THOMAS LEON (DC)
Entity Type:Individual
Prefix:DR
First Name:THOMAS
Middle Name:LEON
Last Name:BLAKE
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 1:3199 CARRIAGE CREEK CT
Mailing Address - Street 2:
Mailing Address - City:HAW RIVER
Mailing Address - State:NC
Mailing Address - Zip Code:27258-9047
Mailing Address - Country:US
Mailing Address - Phone:336-261-3113
Mailing Address - Fax:
Practice Address - Street 1:104 NORTH GREENSBORO STREET
Practice Address - Street 2:
Practice Address - City:LIBERTY
Practice Address - State:NC
Practice Address - Zip Code:27298-3203
Practice Address - Country:US
Practice Address - Phone:336-622-1600
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-12-05
Last Update Date:2007-08-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC2074111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC890830HMedicaid
NC890830HMedicaid
NCT93386Medicare UPIN