Provider Demographics
NPI:1902158280
Name:HAIRSTON, BLAKE EDWARD
Entity Type:Individual
Prefix:
First Name:BLAKE
Middle Name:EDWARD
Last Name:HAIRSTON
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:590 NORTHFORK RD
Mailing Address - Street 2:
Mailing Address - City:MARTINSVILLE
Mailing Address - State:VA
Mailing Address - Zip Code:24112-1353
Mailing Address - Country:US
Mailing Address - Phone:276-734-6140
Mailing Address - Fax:
Practice Address - Street 1:590 NORTHFORK RD
Practice Address - Street 2:
Practice Address - City:MARTINSVILLE
Practice Address - State:VA
Practice Address - Zip Code:24112-1353
Practice Address - Country:US
Practice Address - Phone:276-734-6140
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-10-10
Last Update Date:2012-10-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171M00000XOther Service ProvidersCase Manager/Care Coordinator