1649602723 NPI number — TIMOTHY E. BLAKE PT, DPT, CSCS

Table of content: TIMOTHY E. BLAKE PT, DPT, CSCS (NPI 1649602723)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1649602723 NPI number — TIMOTHY E. BLAKE PT, DPT, CSCS

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
BLAKE
Provider First Name:
TIMOTHY
Provider Middle Name:
E.
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
PT, DPT, CSCS
Provider Gender Code:
M

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1649602723
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
09/16/2016
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
1115 BOULDERS PKWY
Provider Second Line Business Mailing Address:
SUITE 200
Provider Business Mailing Address City Name:
NORTH CHESTERFIELD
Provider Business Mailing Address State Name:
VA
Provider Business Mailing Address Postal Code:
23225-4067
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
804-560-5595
Provider Business Mailing Address Fax Number:
804-560-9029

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
5899 BREMO RD
Provider Second Line Business Practice Location Address:
SUITE 100
Provider Business Practice Location Address City Name:
RICHMOND
Provider Business Practice Location Address State Name:
VA
Provider Business Practice Location Address Postal Code:
23226-1935
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
804-285-2645
Provider Business Practice Location Address Fax Number:
804-287-2786
Provider Enumeration Date:
07/31/2013

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 225100000X , with the licence number:  2305208076 , registered in the state of VA ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: C05954 . This is a "GROUP MEDICARE PTAN" identifier , issued by the state of ( VA ) . This identifiers is of the category "OTHER".
  • Identifier: 1649602723 . This is a "MEDICAID QMB ONLY" identifier , issued by the state of ( VA ) . This identifiers is of the category "OTHER".




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