Provider Demographics
NPI:1730427758
Name:EYSTER, BLAKE (PTA)
Entity type:Individual
Prefix:
First Name:BLAKE
Middle Name:
Last Name:EYSTER
Suffix:
Gender:M
Credentials:PTA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:769 WAGNER RD
Mailing Address - Street 2:
Mailing Address - City:BELLVILLE
Mailing Address - State:OH
Mailing Address - Zip Code:44813-8710
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:769 WAGNER RD
Practice Address - Street 2:
Practice Address - City:BELLVILLE
Practice Address - State:OH
Practice Address - Zip Code:44813-8710
Practice Address - Country:US
Practice Address - Phone:419-571-7888
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2013-01-25
Last Update Date:2013-01-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH07613225200000X
TX2086810225200000X
CA9964225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant