Provider Demographics
NPI:1750401667
Name:BLACK, DONALD CHARLES
Entity type:Individual
Prefix:MR
First Name:DONALD
Middle Name:CHARLES
Last Name:BLACK
Suffix:
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:HC 70 BOX 530
Mailing Address - Street 2:
Mailing Address - City:DAVIS
Mailing Address - State:WV
Mailing Address - Zip Code:26260-9718
Mailing Address - Country:US
Mailing Address - Phone:304-866-4554
Mailing Address - Fax:
Practice Address - Street 1:HC 60 BOX 98
Practice Address - Street 2:
Practice Address - City:THOMAS
Practice Address - State:WV
Practice Address - Zip Code:26292-9704
Practice Address - Country:US
Practice Address - Phone:304-463-4181
Practice Address - Fax:304-463-4190
Is Sole Proprietor?:No
Enumeration Date:2007-04-02
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WVPT00602225100000X
PAPT002030L225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist