Provider Demographics
NPI:1053749911
Name:KNIGHT, BLAKE (LMT)
Entity type:Individual
Prefix:
First Name:BLAKE
Middle Name:
Last Name:KNIGHT
Suffix:
Gender:M
Credentials:LMT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:820 CRATER LAKE AVE
Mailing Address - Street 2:SUITE 113
Mailing Address - City:MEDFORD
Mailing Address - State:OR
Mailing Address - Zip Code:97504-6581
Mailing Address - Country:US
Mailing Address - Phone:541-770-1606
Mailing Address - Fax:
Practice Address - Street 1:820 CRATER LAKE AVE
Practice Address - Street 2:SUITE 113
Practice Address - City:MEDFORD
Practice Address - State:OR
Practice Address - Zip Code:97504-6581
Practice Address - Country:US
Practice Address - Phone:541-770-1606
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2013-10-30
Last Update Date:2021-08-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR20099225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist