Provider Demographics
NPI:1336218221
Name:DR. THOMAS L BLAKE PA
Entity Type:Organization
Organization Name:DR. THOMAS L BLAKE PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:THOMAS
Authorized Official - Middle Name:L
Authorized Official - Last Name:BLAKE
Authorized Official - Suffix:
Authorized Official - Credentials:DC
Authorized Official - Phone:336-622-1600
Mailing Address - Street 1:PO BOX 1185
Mailing Address - Street 2:
Mailing Address - City:LIBERTY
Mailing Address - State:NC
Mailing Address - Zip Code:27298-1185
Mailing Address - Country:US
Mailing Address - Phone:336-622-1600
Mailing Address - Fax:336-622-1600
Practice Address - Street 1:104 N GREENSBORO STREET
Practice Address - Street 2:
Practice Address - City:LIBERTY
Practice Address - State:NC
Practice Address - Zip Code:27298
Practice Address - Country:US
Practice Address - Phone:336-622-1600
Practice Address - Fax:336-622-1600
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-11-07
Last Update Date:2008-03-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC2074111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111N00000XChiropractic ProvidersChiropractorGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC890830HMedicaid
NC232182Medicare PIN
NCT93386Medicare UPIN