Healthcare Provider Details

I. General information

NPI: 1306360177
Provider Name (Legal Business Name): MR. DESMOND EUGENE BLAKE SR.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/02/2017
Last Update Date: 08/07/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3201 FONDREN RD
HOUSTON TX
77063
US

IV. Provider business mailing address

3201 FONDREN RD
HOUSTON TX
77063
US

V. Phone/Fax

Practice location:
  • Phone: 832-594-5758
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1744P3200X
TaxonomyProsthetics Case Management
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: