MEDICARE: BLAKE BERT ROYLANCE 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	111N00000X	Chiropractor	CH61024794	WA

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	CH61024794	OTHER	WA	INSURANCE

General Provider Information

NPI Number	:	1558909440
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	BLAKE BERT ROYLANCE DC

Provider Business Mailing Address
First Line	:	1342 S PIONEER WAY
Second Line	:
City	:	MOSES LAKE
State	:	WA
Zip	:	98837-2410
Country	:	US
Telephone Number	:	509-855-6482
Fax Number	:

Provider Business Practice Location Address
First Line	:	1342 S PIONEER WAY
Second Line	:
City	:	MOSES LAKE
State	:	WA
Zip	:	98837-2410
Country	:	US
Telephone Number	:	509-855-6482
Fax Number	:

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

Provider Enumeration Date	:	12/11/2019
Last Update Date	:	07/15/2022

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Directions to “ BLAKE BERT ROYLANCE DC” Practice Location

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