Provider Demographics
NPI:1659035996
Name:BLACK, MIGUEL
Entity Type:Individual
Prefix:
First Name:MIGUEL
Middle Name:
Last Name:BLACK
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:392 CENTRAL AVE UNIT 7806
Mailing Address - Street 2:
Mailing Address - City:JERSEY CITY
Mailing Address - State:NJ
Mailing Address - Zip Code:07307-7623
Mailing Address - Country:US
Mailing Address - Phone:201-952-1269
Mailing Address - Fax:201-526-7308
Practice Address - Street 1:5 LAIDLAW AVE APT 105
Practice Address - Street 2:
Practice Address - City:JERSEY CITY
Practice Address - State:NJ
Practice Address - Zip Code:07306-1550
Practice Address - Country:US
Practice Address - Phone:646-578-0037
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-10-22
Last Update Date:2021-10-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
172A00000X, 343900000X, 347E00000X
NJB50095470001842343900000X, 347C00000X, 347E00000X, 172A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes172A00000XOther Service ProvidersDriver
No343900000XTransportation ServicesNon-emergency Medical Transport (VAN)
No347C00000XTransportation ServicesPrivate Vehicle
No347E00000XTransportation ServicesTransportation Broker