Provider Demographics
NPI:1932645694
Name:BLACK, KHURI
Entity Type:Individual
Prefix:
First Name:KHURI
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 1:17586 38TH RD N
Mailing Address - Street 2:
Mailing Address - City:LOXAHATCHEE
Mailing Address - State:FL
Mailing Address - Zip Code:33470-5414
Mailing Address - Country:US
Mailing Address - Phone:561-568-1091
Mailing Address - Fax:
Practice Address - Street 1:10501 FGCU BLVD S
Practice Address - Street 2:
Practice Address - City:FORT MYERS
Practice Address - State:FL
Practice Address - Zip Code:33965-6502
Practice Address - Country:US
Practice Address - Phone:561-568-1091
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-01-18
Last Update Date:2017-01-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program