Healthcare Provider Details

I. General information

NPI: 1972666774
Provider Name (Legal Business Name): RICHARD DANIEL BLAKE DC
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/19/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

8 GLEN ROAD POWERHOUSE MALL
W LEBANON NH
03784
US

IV. Provider business mailing address

BOX 20 8 GLEN ROAD POWERHOUSE MALL
W LEBANON NH
03784
US

V. Phone/Fax

Practice location:
  • Phone: 603-298-6500
  • Fax: 603-298-6525
Mailing address:
  • Phone: 603-298-6500
  • Fax: 603-298-6525

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code111N00000X
TaxonomyChiropractor
License Number156A
License Number StateNH

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: