MEDICARE: BLAKE'S MOBILE MEDICAL LABS AND SERVICES, LLC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	172V00000X	Community Health Worker

General Provider Information

NPI Number	:	1083298194
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	BLAKE'S MOBILE MEDICAL LABS AND SERVICES, LLC

Provider Business Mailing Address
First Line	:	3201 EDWARDS MILL RD STE 141
Second Line	:
City	:	RALEIGH
State	:	NC
Zip	:	27612-5371
Country	:	US
Telephone Number	:	919-400-0383
Fax Number	:

Provider Business Practice Location Address
First Line	:	3201 EDWARDS MILL RD STE 141
Second Line	:
City	:	RALEIGH
State	:	NC
Zip	:	27612-5371
Country	:	US
Telephone Number	:	919-400-0383
Fax Number	:

Authorized Official
Title or Position	:	CEO
Name	:	NICOLE BLAKE
Credential	:
Telephone Number	:	919-400-0383

Provider Enumeration Date	:	05/06/2021
Last Update Date	:	05/06/2021

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