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General NPI Number Information
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NPI Number | 1912142241
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Entity Type | Organization
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Legal Business Name | MICHAEL G BLAKE AND ASSOCIATES INC.
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Dates
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Enumeration Date | 12/16/2008
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Last Update Date | 12/16/2008
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Provider Practice Location Address
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Address Line | 124 W COAL AVE
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City | GALLUP
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State | NM
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Zip | 87301-6206
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Country | US
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Telephone | 505-722-2020
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Fax | 505-863-2204
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Provider Business Mailing Address
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Address Line | 124 WEST COAL AVE
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City | GALLUP
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State | NM
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Zip | 87301
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Country | US
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Telephone | 505-722-2020
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Fax | 505-863-2204
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Authorized Official
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Title or Position | OPTOMETRIST
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Name | DR. MICHAEL G BLAKE
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Credential | O.D.
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Telephone | 505-722-2020
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 152W00000X
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Taxonomy Name | Optometrist
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License Number |
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License Number State |
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