Provider Demographics
NPI:1720645724
Name:BLACK, BENJAMIN DAVIS (DC)
Entity Type:Individual
Prefix:
First Name:BENJAMIN
Middle Name:DAVIS
Last Name:BLACK
Suffix:
Gender:M
Credentials:DC
Other - Prefix:
Other - First Name:BEN
Other - Middle Name:
Other - Last Name:BLACK
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:DC
Mailing Address - Street 1:19850 OLD SCENIC HWY STE 400
Mailing Address - Street 2:
Mailing Address - City:ZACHARY
Mailing Address - State:LA
Mailing Address - Zip Code:70791-7384
Mailing Address - Country:US
Mailing Address - Phone:225-570-8404
Mailing Address - Fax:225-570-8406
Practice Address - Street 1:14395 GREENWELL SPRINGS RD STE A
Practice Address - Street 2:
Practice Address - City:GREENWELL SPRINGS
Practice Address - State:LA
Practice Address - Zip Code:70739-3340
Practice Address - Country:US
Practice Address - Phone:225-570-8404
Practice Address - Fax:225-570-8406
Is Sole Proprietor?:No
Enumeration Date:2019-05-24
Last Update Date:2019-05-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA1868111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
LA1868OtherSTATE LICENSE