Provider Demographics
NPI:1114567005
Name:BLACK, ANTHONY
Entity Type:Individual
Prefix:MR
First Name:ANTHONY
Middle Name:
Last Name:BLACK
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2202 AUBIN LN APT 404
Mailing Address - Street 2:
Mailing Address - City:BATON ROUGE
Mailing Address - State:LA
Mailing Address - Zip Code:70816-8294
Mailing Address - Country:US
Mailing Address - Phone:225-223-5068
Mailing Address - Fax:
Practice Address - Street 1:2202 AUBIN LN APT 404
Practice Address - Street 2:
Practice Address - City:BATON ROUGE
Practice Address - State:LA
Practice Address - Zip Code:70816-8294
Practice Address - Country:US
Practice Address - Phone:225-223-5068
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-01-09
Last Update Date:2020-01-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3747A0650XNursing Service Related ProvidersTechnicianAttendant Care Provider