Provider Demographics
NPI:1679868103
Name:BLACK, ROBERT
Entity Type:Individual
Prefix:
First Name:ROBERT
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 1:7715 MAINLAND DR
Mailing Address - Street 2:SUITE 108
Mailing Address - City:SAN ANTONIO
Mailing Address - State:TX
Mailing Address - Zip Code:78250-6007
Mailing Address - Country:US
Mailing Address - Phone:210-520-6481
Mailing Address - Fax:866-686-2859
Practice Address - Street 1:5959 SHALLOWFORD RD
Practice Address - Street 2:SUITE 443
Practice Address - City:CHATTANOOGA
Practice Address - State:TN
Practice Address - Zip Code:37421-2285
Practice Address - Country:US
Practice Address - Phone:423-756-2268
Practice Address - Fax:423-266-9690
Is Sole Proprietor?:No
Enumeration Date:2011-06-13
Last Update Date:2011-06-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes247200000XTechnologists, Technicians & Other Technical Service ProvidersTechnician, Other