Provider Demographics
NPI:1063038297
Name:BLACK ROSE ELITE
Entity Type:Organization
Organization Name:BLACK ROSE ELITE
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:TIFFANY
Authorized Official - Middle Name:
Authorized Official - Last Name:STARKS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:931-561-4569
Mailing Address - Street 1:600 COUNTRY CLUB DR APT 72
Mailing Address - Street 2:
Mailing Address - City:NEW ALBANY
Mailing Address - State:IN
Mailing Address - Zip Code:47150-4145
Mailing Address - Country:US
Mailing Address - Phone:812-924-7196
Mailing Address - Fax:
Practice Address - Street 1:757 E LEWIS AND CLARK PKWY
Practice Address - Street 2:
Practice Address - City:CLARKSVILLE
Practice Address - State:IN
Practice Address - Zip Code:47129-2269
Practice Address - Country:US
Practice Address - Phone:812-924-7196
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2020-06-23
Last Update Date:2020-06-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage TherapistGroup - Single Specialty