MEDICARE: ERNESTINE TINA BLAKE LMT

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	225700000X	Massage Therapist	0025655	CO

General Provider Information

NPI Number	:	1962209742
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	ERNESTINE TINA BLAKE LMT

Provider Business Mailing Address
First Line	:	PO BOX 460301
Second Line	:
City	:	AURORA
State	:	CO
Zip	:	80046-0301
Country	:	US
Telephone Number	:	303-505-7763
Fax Number	:

Provider Business Practice Location Address
First Line	:	500 VILLAGE ROAD
Second Line	:
City	:	BRECKENRIDGE
State	:	CO
Zip	:	80424
Country	:	US
Telephone Number	:	303-505-7763
Fax Number	:

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

Provider Enumeration Date	:	02/27/2025
Last Update Date	:	03/11/2026

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