Provider Demographics
NPI:1013221738
Name:BLACK, JOHN WALTON
Entity Type:Individual
Prefix:
First Name:JOHN
Middle Name:WALTON
Last Name:BLACK
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 1:932 PEARL ST
Mailing Address - Street 2:
Mailing Address - City:BOWLING GREEN
Mailing Address - State:OH
Mailing Address - Zip Code:43402-2613
Mailing Address - Country:US
Mailing Address - Phone:419-270-2774
Mailing Address - Fax:
Practice Address - Street 1:932 PEARL ST
Practice Address - Street 2:
Practice Address - City:BOWLING GREEN
Practice Address - State:OH
Practice Address - Zip Code:43402-2613
Practice Address - Country:US
Practice Address - Phone:419-270-2774
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2010-08-05
Last Update Date:2010-08-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332B00000XSuppliersDurable Medical Equipment & Medical Supplies
No332BC3200XSuppliersDurable Medical Equipment & Medical SuppliesCustomized Equipment