Healthcare Provider Details

I. General information

NPI: 1285658302
Provider Name (Legal Business Name): BLAKE LOUIS HOWARD D.C.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/26/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4700 N CLOVERDALE RD STE 103
BOISE ID
83713-1067
US

IV. Provider business mailing address

5658 BLOOM ST
BOISE ID
83703-3463
US

V. Phone/Fax

Practice location:
  • Phone: 208-658-8326
  • Fax: 208-658-0100
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code111NS0005X
TaxonomySports Physician Chiropractor
License NumberCHIA-1166
License Number StateID

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: