Provider Demographics
NPI:1972538346
Name:BLACK, HAROLD LEE (DC)
Entity Type:Individual
Prefix:
First Name:HAROLD
Middle Name:LEE
Last Name:BLACK
Suffix:
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 1:1315 HIGHWAY 1187 STE 101
Mailing Address - Street 2:
Mailing Address - City:MANSFIELD
Mailing Address - State:TX
Mailing Address - Zip Code:76063-6134
Mailing Address - Country:US
Mailing Address - Phone:817-473-6151
Mailing Address - Fax:
Practice Address - Street 1:1315 HIGHWAY 1187 STE 101
Practice Address - Street 2:
Practice Address - City:MANSFIELD
Practice Address - State:TX
Practice Address - Zip Code:76063-6134
Practice Address - Country:US
Practice Address - Phone:817-473-6151
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-12
Last Update Date:2007-12-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXDC4320111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
T12219Medicare UPIN