Provider Demographics
NPI:1467284612
Name:BLACK STAR PHYSICAL THERAPY AND WELLNESS LLC
Entity type:Organization
Organization Name:BLACK STAR PHYSICAL THERAPY AND WELLNESS LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:NATASHA
Authorized Official - Middle Name:
Authorized Official - Last Name:TAYLOR
Authorized Official - Suffix:
Authorized Official - Credentials:PT
Authorized Official - Phone:716-523-8116
Mailing Address - Street 1:6403 WOODSIDE CT
Mailing Address - Street 2:
Mailing Address - City:VAN BUREN TOWNSHIP
Mailing Address - State:MI
Mailing Address - Zip Code:48111-5142
Mailing Address - Country:US
Mailing Address - Phone:716-523-8116
Mailing Address - Fax:
Practice Address - Street 1:6403 WOODSIDE CT
Practice Address - Street 2:
Practice Address - City:VAN BUREN TOWNSHIP
Practice Address - State:MI
Practice Address - Zip Code:48111-5142
Practice Address - Country:US
Practice Address - Phone:716-523-8116
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2024-08-16
Last Update Date:2024-08-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2251X0800XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistOrthopedicGroup - Single Specialty