=====================================================
General NPI Number Information
=====================================================
NPI Number | 1265327530
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | BLAKE FREDERICK ROSE PT, DPT
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 06/09/2025
-----------------------------------------------------
Last Update Date | 06/09/2025
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 900 HAMMOND ST STE D
-----------------------------------------------------
City | BANGOR
-----------------------------------------------------
State | ME
-----------------------------------------------------
Zip | 04401-4378
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 207-973-6356
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 105A GRIFFIN RD
-----------------------------------------------------
City | LEVANT
-----------------------------------------------------
State | ME
-----------------------------------------------------
Zip | 04456
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 805-704-3968
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 225100000X
-----------------------------------------------------
Taxonomy Name | Physical Therapist
-----------------------------------------------------
License Number | PT7117
-----------------------------------------------------
License Number State | ME
-----------------------------------------------------