Provider Demographics
NPI:1407358377
Name:BLACK, BRYAN (MAT, LAT, ATC, CKTP)
Entity Type:Individual
Prefix:
First Name:BRYAN
Middle Name:
Last Name:BLACK
Suffix:
Gender:M
Credentials:MAT, LAT, ATC, CKTP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3946 ICE WAY FORT WAYNE
Mailing Address - Street 2:
Mailing Address - City:FORT WAYNE
Mailing Address - State:IN
Mailing Address - Zip Code:46808
Mailing Address - Country:US
Mailing Address - Phone:517-425-4996
Mailing Address - Fax:
Practice Address - Street 1:3946 ICE WAY FORT WAYNE
Practice Address - Street 2:
Practice Address - City:FORT WAYNE
Practice Address - State:IN
Practice Address - Zip Code:46808
Practice Address - Country:US
Practice Address - Phone:517-425-4996
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-03-06
Last Update Date:2018-03-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN36002703A2255A2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer