Provider Demographics
NPI:1083124556
Name:BLACK, ALEX KENDRICK (ATC)
Entity Type:Individual
Prefix:
First Name:ALEX
Middle Name:KENDRICK
Last Name:BLACK
Suffix:
Gender:M
Credentials:ATC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:834 PATRICK HENRY DR
Mailing Address - Street 2:
Mailing Address - City:BLACKSBURG
Mailing Address - State:VA
Mailing Address - Zip Code:24060-3141
Mailing Address - Country:US
Mailing Address - Phone:513-728-1141
Mailing Address - Fax:
Practice Address - Street 1:150 JAMERSON CENTER (0502) 21 BEAMER WAY
Practice Address - Street 2:
Practice Address - City:BLACKSBURG
Practice Address - State:VA
Practice Address - Zip Code:24061-0001
Practice Address - Country:US
Practice Address - Phone:540-231-6410
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-10-10
Last Update Date:2017-10-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA01260025672255A2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer