Healthcare Provider Details

I. General information

NPI: 1730427758
Provider Name (Legal Business Name): BLAKE EYSTER PTA
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/25/2013
Last Update Date: 01/25/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

769 WAGNER RD
BELLVILLE OH
44813-8710
US

IV. Provider business mailing address

769 WAGNER RD
BELLVILLE OH
44813-8710
US

V. Phone/Fax

Practice location:
  • Phone: 419-571-7888
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225200000X
TaxonomyPhysical Therapy Assistant
License Number07613
License Number StateOH
# 2
Primary TaxonomyN
Taxonomy Code225200000X
TaxonomyPhysical Therapy Assistant
License Number2086810
License Number StateTX
# 3
Primary TaxonomyN
Taxonomy Code225200000X
TaxonomyPhysical Therapy Assistant
License Number9964
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: