=====================================================
General NPI Number Information
=====================================================
NPI Number | 1063784700
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | BLAKE PAIN SOLUTIONS PC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 01/26/2012
-----------------------------------------------------
Last Update Date | 03/19/2012
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 2312 NE 129TH ST
-----------------------------------------------------
City | VANCOUVER
-----------------------------------------------------
State | WA
-----------------------------------------------------
Zip | 98686-3236
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 360-696-5022
-----------------------------------------------------
Fax | 360-696-5445
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | PO BOX 1600
-----------------------------------------------------
City | VANCOUVER
-----------------------------------------------------
State | WA
-----------------------------------------------------
Zip | 98668-1600
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 360-696-5022
-----------------------------------------------------
Fax | 360-696-5445
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | CEO/PHYSICIAN
-----------------------------------------------------
Name | DR. JACOB LEROY BLAKE
-----------------------------------------------------
Credential | MD
-----------------------------------------------------
Telephone | 503-894-0365
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 261QP3300X
-----------------------------------------------------
Taxonomy Name | Pain Clinic/Center
-----------------------------------------------------
License Number | MD60071790
-----------------------------------------------------
License Number State | WA
-----------------------------------------------------