Healthcare Provider Details

I. General information

NPI: 1376152124
Provider Name (Legal Business Name): GEORGE BLAKE
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/28/2020
Last Update Date: 07/28/2020
Certification Date: 07/28/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

581 KAMOKU ST APT 2008
HONOLULU HI
96826-5210
US

IV. Provider business mailing address

581 KAMOKU ST APT 2008
HONOLULU HI
96826-5210
US

V. Phone/Fax

Practice location:
  • Phone: 808-383-5189
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code174200000X
TaxonomyMeals Provider
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: