Provider Demographics
NPI:1033406434
Name:SJ BLACK INVESTMENTS LLC
Entity Type:Organization
Organization Name:SJ BLACK INVESTMENTS LLC
Other - Org Name:ACTIVE CHIROPRACTIC & SPINAL HEALTH
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:SETH
Authorized Official - Middle Name:
Authorized Official - Last Name:BLACK
Authorized Official - Suffix:
Authorized Official - Credentials:DC
Authorized Official - Phone:573-268-8226
Mailing Address - Street 1:501A SOUTH FRANKLIN STREET
Mailing Address - Street 2:
Mailing Address - City:CUBA
Mailing Address - State:MO
Mailing Address - Zip Code:65453
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:501A SOUTH FRANKLIN STREET
Practice Address - Street 2:
Practice Address - City:CUBA
Practice Address - State:MO
Practice Address - Zip Code:65453
Practice Address - Country:US
Practice Address - Phone:573-268-8226
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-07-06
Last Update Date:2011-07-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2008001513111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111N00000XChiropractic ProvidersChiropractorGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO1508044991OtherPROVIDER INDIVIDUAL NPI NUMBER
MO149800001OtherMEDICARE PTAN