Provider Demographics
NPI:1336624535
Name:BLACK, ROBERT G SR
Entity Type:Individual
Prefix:
First Name:ROBERT
Middle Name:G
Last Name:BLACK
Suffix:SR
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 1:3550 HARRISON BLVD STE D
Mailing Address - Street 2:
Mailing Address - City:OGDEN
Mailing Address - State:UT
Mailing Address - Zip Code:84403-2081
Mailing Address - Country:US
Mailing Address - Phone:801-476-4141
Mailing Address - Fax:801-476-2097
Practice Address - Street 1:3550 HARRISON BLVD STE D
Practice Address - Street 2:
Practice Address - City:OGDEN
Practice Address - State:UT
Practice Address - Zip Code:84403-2081
Practice Address - Country:US
Practice Address - Phone:801-476-4141
Practice Address - Fax:801-476-2097
Is Sole Proprietor?:No
Enumeration Date:2018-10-03
Last Update Date:2018-10-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT343568-2401225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist