Provider Demographics
NPI:1063998128
Name:MATLOCK, BLAKE ALAN (DC)
Entity type:Individual
Prefix:DR
First Name:BLAKE
Middle Name:ALAN
Last Name:MATLOCK
Suffix:
Gender:M
Credentials:DC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:8901 S SANTA FE AVE STE A
Mailing Address - Street 2:
Mailing Address - City:OKLAHOMA CITY
Mailing Address - State:OK
Mailing Address - Zip Code:73139-8413
Mailing Address - Country:US
Mailing Address - Phone:405-634-0042
Mailing Address - Fax:
Practice Address - Street 1:8901 S SANTA FE AVE STE A
Practice Address - Street 2:
Practice Address - City:OKLAHOMA CITY
Practice Address - State:OK
Practice Address - Zip Code:73139-8413
Practice Address - Country:US
Practice Address - Phone:405-634-0042
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-07-12
Last Update Date:2018-07-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK4274111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor