Healthcare Provider Details

I. General information

NPI: 1164175477
Provider Name (Legal Business Name): BLAKE MICHAEL BAZA
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 01/27/2022
Last Update Date: 04/28/2026
Certification Date: 04/28/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1870 SENTER RD
SAN JOSE CA
95112-2528
US

IV. Provider business mailing address

1870 SENTER RD
SAN JOSE CA
95112-2528
US

V. Phone/Fax

Practice location:
  • Phone: 408-961-4490
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225400000X
TaxonomyRehabilitation Practitioner
License Number
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: