Provider Demographics
NPI:1427921378
Name:BROUKHIM, BLAKE JOHNATHAN (LAC)
Entity type:Individual
Prefix:
First Name:BLAKE
Middle Name:JOHNATHAN
Last Name:BROUKHIM
Suffix:
Gender:M
Credentials:LAC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:10614 RIVERSIDE DR
Mailing Address - Street 2:
Mailing Address - City:NORTH HOLLYWOOD
Mailing Address - State:CA
Mailing Address - Zip Code:91602-2373
Mailing Address - Country:US
Mailing Address - Phone:818-755-6070
Mailing Address - Fax:818-755-1870
Practice Address - Street 1:10614 RIVERSIDE DR
Practice Address - Street 2:
Practice Address - City:NORTH HOLLYWOOD
Practice Address - State:CA
Practice Address - Zip Code:91602-2373
Practice Address - Country:US
Practice Address - Phone:818-755-6070
Practice Address - Fax:818-755-1870
Is Sole Proprietor?:Yes
Enumeration Date:2025-09-26
Last Update Date:2025-10-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAAC20441171100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171100000XOther Service ProvidersAcupuncturist