Provider Demographics
NPI:1922080019
Name:BLACK, LEO F JR (DC)
Entity Type:Individual
Prefix:
First Name:LEO
Middle Name:F
Last Name:BLACK
Suffix:JR
Gender:M
Credentials:DC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1301 BERTHA HOWE AVE
Mailing Address - Street 2:SUITE 1
Mailing Address - City:MESQUITE
Mailing Address - State:NV
Mailing Address - Zip Code:89027-7502
Mailing Address - Country:US
Mailing Address - Phone:702-346-0800
Mailing Address - Fax:702-346-0801
Practice Address - Street 1:1301 BERTHA HOWE AVE
Practice Address - Street 2:SUITE 1
Practice Address - City:MESQUITE
Practice Address - State:NV
Practice Address - Zip Code:89027-7502
Practice Address - Country:US
Practice Address - Phone:702-346-0800
Practice Address - Fax:702-346-0801
Is Sole Proprietor?:Not Answered
Enumeration Date:2005-11-15
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NVB355111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
NVPIN#V38138OtherLEO BLACK, DC
NVU97228Medicare UPIN