Provider Demographics
NPI:1689632838
Name:BLACK BELT MEDICAL INC.
Entity Type:Organization
Organization Name:BLACK BELT MEDICAL INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO/PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:JERRY
Authorized Official - Middle Name:
Authorized Official - Last Name:CARL
Authorized Official - Suffix:JR
Authorized Official - Credentials:
Authorized Official - Phone:251-633-8090
Mailing Address - Street 1:7856 WESTSIDE PARK DR
Mailing Address - Street 2:SUITE C
Mailing Address - City:MOBILE
Mailing Address - State:AL
Mailing Address - Zip Code:36695-8541
Mailing Address - Country:US
Mailing Address - Phone:251-633-8090
Mailing Address - Fax:251-633-6941
Practice Address - Street 1:1004 JEFF DAVIS AVE
Practice Address - Street 2:
Practice Address - City:SELMA
Practice Address - State:AL
Practice Address - Zip Code:36701-4519
Practice Address - Country:US
Practice Address - Phone:334-872-9721
Practice Address - Fax:334-874-4923
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-05-03
Last Update Date:2008-03-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332B00000XSuppliersDurable Medical Equipment & Medical Supplies
Provider Identifiers
StateIdentifier IDID TypeIssuer
AL51516028OtherBLUE CROSS BLUE SHIELD
AL51516028OtherBLUE CROSS BLUE SHIELD