Provider Demographics
NPI:1962988402
Name:CARROLL, BLAKE DANTON (DC)
Entity type:Individual
Prefix:DR
First Name:BLAKE
Middle Name:DANTON
Last Name:CARROLL
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 1:16104 BUCKBOARD CIR
Mailing Address - Street 2:
Mailing Address - City:TYLER
Mailing Address - State:TX
Mailing Address - Zip Code:75703-7504
Mailing Address - Country:US
Mailing Address - Phone:903-316-4517
Mailing Address - Fax:
Practice Address - Street 1:6573 OLD JACKSONVILLE HWY STE 100
Practice Address - Street 2:
Practice Address - City:TYLER
Practice Address - State:TX
Practice Address - Zip Code:75703-0722
Practice Address - Country:US
Practice Address - Phone:903-617-6106
Practice Address - Fax:903-617-6857
Is Sole Proprietor?:No
Enumeration Date:2018-07-18
Last Update Date:2018-07-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX13869111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor