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General NPI Number Information
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NPI Number | 1568148336
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Entity Type | Individual
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Provider Name | BLAKE DALY RD
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Gender | Male
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Dates
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Enumeration Date | 06/26/2023
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Last Update Date | 05/07/2024
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Provider Practice Location Address
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Address Line | 19333 BEAR VALLEY RD STE 103
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City | APPLE VALLEY
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State | CA
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Zip | 92308-5149
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Country | US
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Telephone | 714-618-9500
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Fax |
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Provider Business Mailing Address
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Address Line | 415 SOUTH 28TH AVENUE HATTIESBURG
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City | HATTIESBURG
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State | MS
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Zip | 39401
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Country | US
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Telephone | 601-579-5210
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Fax | 601-268-5733
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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 | 133V00000X
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Taxonomy Name | Registered Dietitian
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License Number | D-2197
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License Number State | MS
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