Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 111NS0005X | Chiropractic Sports Physician | 5509 | OR |
NPI | 1295162006 |
---|---|
Provider Name | Dr. Blake Testa |
First Address | Salem, OR 97302-2154 |
Second Address | Salem, OR 97302-2154 |
Gender | M |
NPI Entity type | Individual |
Is Sole Proprietor | No |
Is Organization Subpart | N/A |
Enumeration Date | 11/10/2013 |
Last Update Date | 11/10/2013 |