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General NPI Number Information
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NPI Number | 1174650071
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Entity Type | Individual
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Provider Name | RICHARD GARY BLAKE R.D.O.
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Gender | Male
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Dates
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Enumeration Date | 02/27/2007
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Last Update Date | 07/08/2007
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Provider Practice Location Address
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Address Line | 21835 VENTURA BLVD
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City | WOODLAND HILLS
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State | CA
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Zip | 91364-1838
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Country | US
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Telephone | 818-883-9567
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Fax | 818-883-5261
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Provider Business Mailing Address
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Address Line | 1086 DEEP WOOD DR
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City | WESTLAKE VILLAGE
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State | CA
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Zip | 91362-4215
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Country | US
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Telephone | 805-495-4046
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Fax | 808-883-5261
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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 | 156FX1800X
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Taxonomy Name | Optician
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License Number | D006638
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License Number State | CA
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