Provider Demographics
NPI:1063998276
Name:BLAKE IN HOME HEALTH SERVICE LLC
Entity type:Organization
Organization Name:BLAKE IN HOME HEALTH SERVICE LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:THOMAS
Authorized Official - Middle Name:EVERTT
Authorized Official - Last Name:BLAKE
Authorized Official - Suffix:SR
Authorized Official - Credentials:DO
Authorized Official - Phone:314-243-6745
Mailing Address - Street 1:7220 N LINDBERGH BLVD # 210
Mailing Address - Street 2:
Mailing Address - City:HAZELWOOD
Mailing Address - State:MO
Mailing Address - Zip Code:63042-2019
Mailing Address - Country:US
Mailing Address - Phone:314-224-8411
Mailing Address - Fax:
Practice Address - Street 1:7220 N LINDBERGH BLVD # 210
Practice Address - Street 2:
Practice Address - City:HAZELWOOD
Practice Address - State:MO
Practice Address - Zip Code:63042-2019
Practice Address - Country:US
Practice Address - Phone:314-224-8411
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2018-07-11
Last Update Date:2022-02-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO251E00000X, 253Z00000X, 374U00000X
163WH0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes163WH0200XNursing Service ProvidersRegistered NurseHome HealthGroup - Multi-Specialty
No251E00000XAgenciesHome HealthGroup - Multi-Specialty
No253Z00000XAgenciesIn Home Supportive CareGroup - Multi-Specialty
No374U00000XNursing Service Related ProvidersHome Health AideGroup - Multi-Specialty