Provider Demographics
NPI:1043817711
Name:BLACK, OLIVIA MARTHA
Entity Type:Individual
Prefix:
First Name:OLIVIA
Middle Name:MARTHA
Last Name:BLACK
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5201 IRWIN RD
Mailing Address - Street 2:
Mailing Address - City:HUNTINGTON
Mailing Address - State:WV
Mailing Address - Zip Code:25705-3264
Mailing Address - Country:US
Mailing Address - Phone:304-360-7946
Mailing Address - Fax:
Practice Address - Street 1:5201 IRWIN RD
Practice Address - Street 2:
Practice Address - City:HUNTINGTON
Practice Address - State:WV
Practice Address - Zip Code:25705-3264
Practice Address - Country:US
Practice Address - Phone:304-360-7946
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-10-06
Last Update Date:2020-10-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3747P1801XNursing Service Related ProvidersTechnicianPersonal Care Attendant