MEDICARE: BLAKE HOME HEALTHCARE, LLC

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	251E00000X	Home Health Agency

General Provider Information

NPI Number	:	1356967145
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	BLAKE HOME HEALTHCARE, LLC

Provider Business Mailing Address
First Line	:	3524 CARTER RD
Second Line	:
City	:	PORTSMOUTH
State	:	VA
Zip	:	23703-3811
Country	:	US
Telephone Number	:	757-637-5073
Fax Number	:

Provider Business Practice Location Address
First Line	:	5709 S LABURNUM AVE
Second Line	:
City	:	RICHMOND
State	:	VA
Zip	:	23231-4420
Country	:	US
Telephone Number	:	804-545-1974
Fax Number	:

Authorized Official
Title or Position	:	DIRECTOR/PRESIDENT
Name	:	CHARLES MONTEL MAYO
Credential	:
Telephone Number	:	804-545-1974

Provider Enumeration Date	:	06/17/2020
Last Update Date	:	06/17/2020

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