Provider Demographics
NPI:1013933589
Name:BLAKE, KENNETH (HIS)
Entity Type:Individual
Prefix:
First Name:KENNETH
Middle Name:
Last Name:BLAKE
Suffix:
Gender:M
Credentials:HIS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:39000 BOB HOPE DRIVE PROBST 315
Mailing Address - Street 2:
Mailing Address - City:RANCHO MIRAGE
Mailing Address - State:CA
Mailing Address - Zip Code:92270-3221
Mailing Address - Country:US
Mailing Address - Phone:760-625-6616
Mailing Address - Fax:442-666-3766
Practice Address - Street 1:39000 BOB HOPE DRIVE PROBST 315
Practice Address - Street 2:
Practice Address - City:RANCHO MIRAGE
Practice Address - State:CA
Practice Address - Zip Code:92270-3221
Practice Address - Country:US
Practice Address - Phone:760-625-6616
Practice Address - Fax:442-666-3766
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-15
Last Update Date:2019-06-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CADC172371111N00000X
CADC17237111N00000X
CAHA7407237700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes237700000XSpeech, Language and Hearing Service ProvidersHearing Instrument Specialist
No111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
CADC172371OtherINSURANCE COMPANIES
CAU51819Medicare UPIN
CADC0172371Medicare ID - Type UnspecifiedPROVIDER IDENTIFICATION