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General NPI Number Information
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NPI Number | 1912046723
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Entity Type | Organization
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Legal Business Name | BRANDON BLAKER O D P C
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Dates
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Enumeration Date | 02/06/2007
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Last Update Date | 01/06/2016
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Provider Practice Location Address
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Address Line | 508 S ADAMS ST
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City | FREDERICKSBURG
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State | TX
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Zip | 78624-4437
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Country | US
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Telephone | 830-997-2504
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Fax | 830-997-5155
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Provider Business Mailing Address
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Address Line | 205 B WEST WATER ST
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City | KERRVILLE
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State | TX
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Zip | 78028
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Country | US
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Telephone | 830-896-4044
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Fax | 830-257-6419
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Authorized Official
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Title or Position | PRESIDENT
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Name | BRANDON J BLAKER
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Credential | O.D.
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Telephone | 830-997-2504
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 332H00000X
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Taxonomy Name | Eyewear Supplier
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License Number | TX6429TG
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License Number State | TX
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