MEDICARE: DR. BLAKE ROBERT PENNOCK II DC

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	390200000X	Student in an Organized Health Care Education/Training Program
2	111N00000X	Chiropractor	8787	AZ

General Provider Information

NPI Number	:	1053877159
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. BLAKE ROBERT PENNOCK II DC

Provider Business Mailing Address
First Line	:	505 W BASELINE RD APT 2142
Second Line	:
City	:	TEMPE
State	:	AZ
Zip	:	85283-5319
Country	:	US
Telephone Number	:	563-249-7446
Fax Number	:

Provider Business Practice Location Address
First Line	:	1501 S YALE ST STE 250
Second Line	:
City	:	FLAGSTAFF
State	:	AZ
Zip	:	86001-7336
Country	:	US
Telephone Number	:	928-557-0707
Fax Number	:

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

Provider Enumeration Date	:	02/13/2019
Last Update Date	:	02/22/2019

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