Provider Demographics
NPI:1558683953
Name:BLACK MOUNTAIN NEURO-MEDICAL TREATMENT CENTER
Entity Type:Organization
Organization Name:BLACK MOUNTAIN NEURO-MEDICAL TREATMENT CENTER
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:BUSINESS MANAGER
Authorized Official - Prefix:DR
Authorized Official - First Name:JACK
Authorized Official - Middle Name:L
Authorized Official - Last Name:ST CLAIR
Authorized Official - Suffix:
Authorized Official - Credentials:ED D
Authorized Official - Phone:828-259-6720
Mailing Address - Street 1:932 OLD US 70 W
Mailing Address - Street 2:
Mailing Address - City:BLACK MOUNTAIN
Mailing Address - State:NC
Mailing Address - Zip Code:28711-2547
Mailing Address - Country:US
Mailing Address - Phone:828-259-6720
Mailing Address - Fax:828-669-3169
Practice Address - Street 1:932 OLD US 70 W
Practice Address - Street 2:
Practice Address - City:BLACK MOUNTAIN
Practice Address - State:NC
Practice Address - Zip Code:28711-2547
Practice Address - Country:US
Practice Address - Phone:828-259-6720
Practice Address - Fax:828-669-3169
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-02-26
Last Update Date:2024-03-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
N/A261QD0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QD0000XAmbulatory Health Care FacilitiesClinic/CenterDental
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC3406437Medicaid
NC3495689Medicaid