Provider Demographics
NPI:1649792565
Name:BLAKE, DAVID
Entity type:Individual
Prefix:
First Name:DAVID
Middle Name:
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 1:522 E LAKE MEAD PKWY STE 5
Mailing Address - Street 2:
Mailing Address - City:HENDERSON
Mailing Address - State:NV
Mailing Address - Zip Code:89015-5573
Mailing Address - Country:US
Mailing Address - Phone:702-486-6714
Mailing Address - Fax:
Practice Address - Street 1:522 E. LAKE MEAD PARKWAY
Practice Address - Street 2:SUITE 5
Practice Address - City:HENDERSON
Practice Address - State:NV
Practice Address - Zip Code:89015
Practice Address - Country:US
Practice Address - Phone:702-486-6714
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-07-12
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171M00000XOther Service ProvidersCase Manager/Care Coordinator