Provider Demographics
NPI:1982820593
Name:BLAKE, PATRICIA (LAC)
Entity Type:Individual
Prefix:MRS
First Name:PATRICIA
Middle Name:
Last Name:BLAKE
Suffix:
Gender:F
Credentials:LAC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:551 TEWA CT
Mailing Address - Street 2:
Mailing Address - City:DEL MAR
Mailing Address - State:CA
Mailing Address - Zip Code:92014-2850
Mailing Address - Country:US
Mailing Address - Phone:858-755-4141
Mailing Address - Fax:
Practice Address - Street 1:12264 EL CAMINO REAL
Practice Address - Street 2:STE. 108
Practice Address - City:SAN DIEGO
Practice Address - State:CA
Practice Address - Zip Code:92130-3058
Practice Address - Country:US
Practice Address - Phone:858-481-0303
Practice Address - Fax:858-481-9797
Is Sole Proprietor?:Yes
Enumeration Date:2007-04-18
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAAC-9648171100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171100000XOther Service ProvidersAcupuncturist