Provider Demographics
NPI:1104717024
Name:CHURCH, BLAKE
Entity type:Individual
Prefix:
First Name:BLAKE
Middle Name:
Last Name:CHURCH
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 1:17321 W HORIZON DR
Mailing Address - Street 2:
Mailing Address - City:NEW BERLIN
Mailing Address - State:WI
Mailing Address - Zip Code:53146-3219
Mailing Address - Country:US
Mailing Address - Phone:414-313-7121
Mailing Address - Fax:
Practice Address - Street 1:17321 W HORIZON DR
Practice Address - Street 2:
Practice Address - City:NEW BERLIN
Practice Address - State:WI
Practice Address - Zip Code:53146-3219
Practice Address - Country:US
Practice Address - Phone:414-313-7121
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2025-07-09
Last Update Date:2025-07-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI4089-35152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist