Provider Demographics
NPI:1619144920
Name:BLACK, LYLE H (MPT)
Entity Type:Individual
Prefix:
First Name:LYLE
Middle Name:H
Last Name:BLACK
Suffix:
Gender:M
Credentials:MPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:248 W 300 N
Mailing Address - Street 2:
Mailing Address - City:LOGAN
Mailing Address - State:UT
Mailing Address - Zip Code:84321-3810
Mailing Address - Country:US
Mailing Address - Phone:435-754-0277
Mailing Address - Fax:435-752-1318
Practice Address - Street 1:248 W 300 N
Practice Address - Street 2:
Practice Address - City:LOGAN
Practice Address - State:UT
Practice Address - Zip Code:84321-3810
Practice Address - Country:US
Practice Address - Phone:435-754-0277
Practice Address - Fax:435-752-1318
Is Sole Proprietor?:No
Enumeration Date:2008-05-15
Last Update Date:2008-09-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT5271519-2401174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
UT$$$$$$$$$001Medicaid