Provider Demographics
NPI:1316009541
Name:BLACK, KWIN ROBERTS (RD)
Entity Type:Individual
Prefix:MRS
First Name:KWIN
Middle Name:ROBERTS
Last Name:BLACK
Suffix:
Gender:F
Credentials:RD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:155 LILLY MOUNTAIN LN
Mailing Address - Street 2:
Mailing Address - City:NORMAN
Mailing Address - State:AR
Mailing Address - Zip Code:71960-8530
Mailing Address - Country:US
Mailing Address - Phone:870-334-2762
Mailing Address - Fax:870-334-2762
Practice Address - Street 1:300 WERNER ST
Practice Address - Street 2:
Practice Address - City:HOT SPRINGS
Practice Address - State:AR
Practice Address - Zip Code:71913-6406
Practice Address - Country:US
Practice Address - Phone:501-622-1000
Practice Address - Fax:501-622-2044
Is Sole Proprietor?:No
Enumeration Date:2006-12-14
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AR0812133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered
Provider Identifiers
StateIdentifier IDID TypeIssuer
AR5X825Medicare UPIN