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General NPI Number Information
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NPI Number | 1053877159
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Entity Type | Individual
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Provider Name | BLAKE ROBERT PENNOCK II DC
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Gender | Male
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Dates
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Enumeration Date | 02/13/2019
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Last Update Date | 02/22/2019
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Provider Practice Location Address
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Address Line | 1501 S YALE ST STE 250
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City | FLAGSTAFF
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State | AZ
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Zip | 86001-7336
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Country | US
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Telephone | 928-557-0707
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Fax |
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Provider Business Mailing Address
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Address Line | 505 W BASELINE RD APT 2142
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City | TEMPE
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State | AZ
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Zip | 85283-5319
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Country | US
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Telephone | 563-249-7446
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Fax |
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 390200000X
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Taxonomy Name | Student in an Organized Health Care Education/Training Program
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License Number |
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License Number State |
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Taxonomy #2
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Taxonomy Code | 111N00000X
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Taxonomy Name | Chiropractor
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License Number | 8787
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License Number State | AZ
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