Healthcare Provider Details

I. General information

NPI: 1275827438
Provider Name (Legal Business Name): BLAKE LEE GUIRGUIS MSW
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/06/2011
Last Update Date: 06/09/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1517 W GARVEY AVE N
WEST COVINA CA
91790-2138
US

IV. Provider business mailing address

1517 W GARVEY AVE N
WEST COVINA CA
91790-2138
US

V. Phone/Fax

Practice location:
  • Phone: 626-962-6061
  • Fax:
Mailing address:
  • Phone: 626-962-6061
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

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

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: