MEDICARE: DR THOMAS BLAKE INC

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

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1912188293
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	DR THOMAS BLAKE INC

Provider Business Mailing Address
First Line	:	PO BOX 1185
Second Line	:
City	:	LIBERTY
State	:	NC
Zip	:	27298-1185
Country	:	US
Telephone Number	:	336-622-1600
Fax Number	:	336-622-1600

Provider Business Practice Location Address
First Line	:	122 N FAYETTEVILLE ST
Second Line	:
City	:	LIBERTY
State	:	NC
Zip	:	27298-3203
Country	:	US
Telephone Number	:	336-622-1600
Fax Number	:	336-622-1600

Authorized Official
Title or Position	:	CHIROPRACTOR
Name	:	DR. THOMAS BLAKE
Credential	:	DC
Telephone Number	:	336-622-1600

Provider Enumeration Date	:	11/15/2007
Last Update Date	:	11/15/2007

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