Provider Demographics
NPI:1407855034
Name:BLACK, MARY M
Entity Type:Individual
Prefix:
First Name:MARY
Middle Name:M
Last Name:BLACK
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:300 W 27TH ST
Mailing Address - Street 2:ATTN: WILLIAM J GUTEKUNST
Mailing Address - City:LUMBERTON
Mailing Address - State:NC
Mailing Address - Zip Code:28358-3075
Mailing Address - Country:US
Mailing Address - Phone:910-671-5000
Mailing Address - Fax:
Practice Address - Street 1:4300 FAYETTEVILLE RD
Practice Address - Street 2:
Practice Address - City:LUMBERTON
Practice Address - State:NC
Practice Address - Zip Code:28358-2677
Practice Address - Country:US
Practice Address - Phone:910-671-5830
Practice Address - Fax:
Is Sole Proprietor?:Not Answered
Enumeration Date:2005-07-15
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NCL000588133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC2992422Medicare ID - Type Unspecified
P71513Medicare UPIN