Provider Demographics
NPI:1326253006
Name:BLACK'S CHIROPRACTIC CLINIC, INC.
Entity Type:Organization
Organization Name:BLACK'S CHIROPRACTIC CLINIC, INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:ED
Authorized Official - Middle Name:J
Authorized Official - Last Name:BLACK
Authorized Official - Suffix:
Authorized Official - Credentials:DC
Authorized Official - Phone:918-358-3509
Mailing Address - Street 1:510 N BROADWAY ST
Mailing Address - Street 2:
Mailing Address - City:CLEVELAND
Mailing Address - State:OK
Mailing Address - Zip Code:74020-2206
Mailing Address - Country:US
Mailing Address - Phone:918-358-3509
Mailing Address - Fax:918-358-3026
Practice Address - Street 1:510 N BROADWAY ST
Practice Address - Street 2:
Practice Address - City:CLEVELAND
Practice Address - State:OK
Practice Address - Zip Code:74020-2206
Practice Address - Country:US
Practice Address - Phone:918-358-3509
Practice Address - Fax:918-358-3026
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-05-14
Last Update Date:2007-08-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111NN0400XChiropractic ProvidersChiropractorNeurologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
OKQDBMFMedicare ID - Type Unspecified