=====================================================
General NPI Number Information
=====================================================
NPI Number | 1912188293
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | DR THOMAS BLAKE INC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 11/15/2007
-----------------------------------------------------
Last Update Date | 11/15/2007
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 122 N FAYETTEVILLE ST
-----------------------------------------------------
City | LIBERTY
-----------------------------------------------------
State | NC
-----------------------------------------------------
Zip | 27298-3203
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 336-622-1600
-----------------------------------------------------
Fax | 336-622-1600
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | PO BOX 1185
-----------------------------------------------------
City | LIBERTY
-----------------------------------------------------
State | NC
-----------------------------------------------------
Zip | 27298-1185
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 336-622-1600
-----------------------------------------------------
Fax | 336-622-1600
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | CHIROPRACTOR
-----------------------------------------------------
Name | DR. THOMAS BLAKE
-----------------------------------------------------
Credential | DC
-----------------------------------------------------
Telephone | 336-622-1600
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 111N00000X
-----------------------------------------------------
Taxonomy Name | Chiropractor
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------