Provider Demographics
NPI:1720154511
Name:BLACK, WAYNE EUGENE (NMD)
Entity Type:Individual
Prefix:DR
First Name:WAYNE
Middle Name:EUGENE
Last Name:BLACK
Suffix:
Gender:M
Credentials:NMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:31615 N 66TH ST
Mailing Address - Street 2:
Mailing Address - City:CAVE CREEK
Mailing Address - State:AZ
Mailing Address - Zip Code:85331-5735
Mailing Address - Country:US
Mailing Address - Phone:602-510-8789
Mailing Address - Fax:
Practice Address - Street 1:31615 N 66TH ST
Practice Address - Street 2:
Practice Address - City:CAVE CREEK
Practice Address - State:AZ
Practice Address - Zip Code:85331-5735
Practice Address - Country:US
Practice Address - Phone:602-510-8789
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-11-26
Last Update Date:2012-12-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ00588175F00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes175F00000XOther Service ProvidersNaturopath