MEDICARE: MARC B BLAKE

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	237700000X	Hearing Instrument Specialist

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	007076923	OTHER	LA	DRIVERS LICENSE

General Provider Information

NPI Number	:	1033876461
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MARC B BLAKE

Provider Business Mailing Address
First Line	:	5750 JOHNSTON ST STE 502
Second Line	:
City	:	LAFAYETTE
State	:	LA
Zip	:	70503-5334
Country	:	US
Telephone Number	:	337-417-9200
Fax Number	:

Provider Business Practice Location Address
First Line	:	2102 MACARTHUR DR STE C
Second Line	:
City	:	ALEXANDRIA
State	:	LA
Zip	:	71301-3763
Country	:	US
Telephone Number	:	866-550-6849
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	11/19/2021
Last Update Date	:	11/19/2021

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Directions to “ MARC B BLAKE ” Practice Location

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