Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 2251S0007X | Physical Therapist - Sports | 004814 | IA |
NPI | 1225326754 |
---|---|
Provider Name | Blake David Reinke |
First Address | Le Mars, IA 51031-0921 |
Second Address | Spirit Lake, IA 51360-1014 |
Gender | M |
NPI Entity type | Individual |
Is Sole Proprietor | No |
Is Organization Subpart | N/A |
Enumeration Date | 18/07/2011 |
Last Update Date | 19/06/2013 |