Provider Demographics
NPI:1073658688
Name:BLACK, TODD A (DC)
Entity Type:Individual
Prefix:
First Name:TODD
Middle Name:A
Last Name:BLACK
Suffix:
Gender:M
Credentials:DC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:546 LONGFIELD AVE
Mailing Address - Street 2:STE 345
Mailing Address - City:LOUISVILLE
Mailing Address - State:KY
Mailing Address - Zip Code:40215-2930
Mailing Address - Country:US
Mailing Address - Phone:502-298-3715
Mailing Address - Fax:502-298-3715
Practice Address - Street 1:546 LONGFIELD AVE STE 345
Practice Address - Street 2:
Practice Address - City:LOUISVILLE
Practice Address - State:KY
Practice Address - Zip Code:40215-2930
Practice Address - Country:US
Practice Address - Phone:502-447-2222
Practice Address - Fax:502-409-8042
Is Sole Proprietor?:Yes
Enumeration Date:2007-02-21
Last Update Date:2018-03-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY4451111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY1285957035OtherWELLNESS CHIROPRACTIC