Healthcare Provider Details

I. General information

NPI: 1366929259
Provider Name (Legal Business Name): MR. ELDRIDGE BLAKE BAKER
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/24/2018
Last Update Date: 07/24/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

153 LEE ROAD 697
OPELIKA AL
36804-0443
US

IV. Provider business mailing address

153 LEE ROAD 697
OPELIKA AL
36804-0443
US

V. Phone/Fax

Practice location:
  • Phone: 334-663-1561
  • Fax:
Mailing address:
  • Phone: 334-663-1561
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code385HR2065X
TaxonomyChild Physical Disabilities Respite Care
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code385H00000X
TaxonomyRespite Care
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code385HR2050X
TaxonomyRespite Care Camp
License Number
License Number State
# 4
Primary TaxonomyN
Taxonomy Code385HR2055X
TaxonomyChild Mental Illness Respite Care
License Number
License Number State
# 5
Primary TaxonomyN
Taxonomy Code251E00000X
TaxonomyHome Health Agency
License Number
License Number State
# 6
Primary TaxonomyN
Taxonomy Code385HR2060X
TaxonomyChild Intellectual and/or Developmental Disabilities Respite Care
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: