Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 156FX1800X | Optician | D006638 | CA |
NPI | 1174650071 |
---|---|
Provider Name | Mr. Richard Gary Blake |
First Address | Westlake Village, CA 91362-4215 |
Second Address | Woodland Hills, CA 91364-1838 |
Gender | M |
NPI Entity type | Individual |
Is Sole Proprietor | Yes |
Is Organization Subpart | N/A |
Enumeration Date | 27/02/2007 |
Last Update Date | 08/07/2007 |