Provider Demographics
NPI:1477965515
Name:BLACK, LIDA (RN)
Entity Type:Individual
Prefix:MRS
First Name:LIDA
Middle Name:
Last Name:BLACK
Suffix:
Gender:F
Credentials:RN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1899 ISLAND FORD RD
Mailing Address - Street 2:
Mailing Address - City:SILVERSTREET
Mailing Address - State:SC
Mailing Address - Zip Code:29145-9340
Mailing Address - Country:US
Mailing Address - Phone:803-276-8813
Mailing Address - Fax:
Practice Address - Street 1:1899 ISLAND FORD RD
Practice Address - Street 2:
Practice Address - City:SILVERSTREET
Practice Address - State:SC
Practice Address - Zip Code:29145-9340
Practice Address - Country:US
Practice Address - Phone:803-276-8813
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2014-05-23
Last Update Date:2014-05-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC15126163W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163W00000XNursing Service ProvidersRegistered Nurse