Healthcare Provider Details

I. General information

NPI: 1053877159
Provider Name (Legal Business Name): BLAKE ROBERT PENNOCK II DC
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 02/13/2019
Last Update Date: 02/22/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1501 S YALE ST STE 250
FLAGSTAFF AZ
86001-7336
US

IV. Provider business mailing address

505 W BASELINE RD APT 2142
TEMPE AZ
85283-5319
US

V. Phone/Fax

Practice location:
  • Phone: 928-557-0707
  • Fax:
Mailing address:
  • Phone: 563-249-7446
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code111N00000X
TaxonomyChiropractor
License Number8787
License Number StateAZ
# 2
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number StateNULL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: