Healthcare Provider Details

I. General information

NPI: 1912142241
Provider Name (Legal Business Name): MICHAEL G BLAKE AND ASSOCIATES INC.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/16/2008
Last Update Date: 12/16/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

124 W COAL AVE
GALLUP NM
87301-6206
US

IV. Provider business mailing address

124 WEST COAL AVE
GALLUP NM
87301
US

V. Phone/Fax

Practice location:
  • Phone: 505-722-2020
  • Fax: 505-863-2204
Mailing address:
  • Phone: 505-722-2020
  • Fax: 505-863-2204

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code152W00000X
TaxonomyOptometrist
License Number
License Number State

VIII. Authorized Official

Name: DR. MICHAEL G BLAKE
Title or Position: OPTOMETRIST
Credential: O.D.
Phone: 505-722-2020