Provider Demographics
NPI:1114082401
Name:BLACK, STEFAN RICHARD (DC)
Entity Type:Individual
Prefix:DR
First Name:STEFAN
Middle Name:RICHARD
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 1:15100 SE 38TH ST
Mailing Address - Street 2:305B
Mailing Address - City:BELLEVUE
Mailing Address - State:WA
Mailing Address - Zip Code:98006
Mailing Address - Country:US
Mailing Address - Phone:425-289-0092
Mailing Address - Fax:425-289-0095
Practice Address - Street 1:15100 SE 38TH ST
Practice Address - Street 2:305B
Practice Address - City:BELLEVUE
Practice Address - State:WA
Practice Address - Zip Code:98006
Practice Address - Country:US
Practice Address - Phone:425-289-0092
Practice Address - Fax:425-289-0095
Is Sole Proprietor?:No
Enumeration Date:2006-12-27
Last Update Date:2012-05-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WACH00034220111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
U98431Medicare UPIN
WAG8800640Medicare ID - Type Unspecified