Provider Demographics
NPI:1073614491
Name:BLACK, ROBERT H (DC)
Entity Type:Individual
Prefix:DR
First Name:ROBERT
Middle Name:H
Last Name:BLACK
Suffix:
Gender:M
Credentials:DC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3318 BARDSTOWN RD
Mailing Address - Street 2:
Mailing Address - City:LOUISVILLE
Mailing Address - State:KY
Mailing Address - Zip Code:40218-4602
Mailing Address - Country:US
Mailing Address - Phone:502-456-5353
Mailing Address - Fax:502-456-4266
Practice Address - Street 1:3318 BARDSTOWN RD
Practice Address - Street 2:
Practice Address - City:LOUISVILLE
Practice Address - State:KY
Practice Address - Zip Code:40218-4602
Practice Address - Country:US
Practice Address - Phone:502-456-5353
Practice Address - Fax:502-456-4266
Is Sole Proprietor?:Yes
Enumeration Date:2006-09-26
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY4519111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY85002293Medicaid
KY0712201Medicare PIN