Provider Demographics
NPI:1326429713
Name:BLACK, KAYLA N (OD)
Entity Type:Individual
Prefix:DR
First Name:KAYLA
Middle Name:N
Last Name:BLACK
Suffix:
Gender:F
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4424 S 7TH ST
Mailing Address - Street 2:
Mailing Address - City:TERRE HAUTE
Mailing Address - State:IN
Mailing Address - Zip Code:47802-4304
Mailing Address - Country:US
Mailing Address - Phone:812-299-3937
Mailing Address - Fax:812-299-8670
Practice Address - Street 1:4424 S 7TH ST
Practice Address - Street 2:
Practice Address - City:TERRE HAUTE
Practice Address - State:IN
Practice Address - Zip Code:47802-4304
Practice Address - Country:US
Practice Address - Phone:812-299-3937
Practice Address - Fax:812-299-8670
Is Sole Proprietor?:Yes
Enumeration Date:2015-06-11
Last Update Date:2015-06-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN18003899A152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist