Provider Demographics
NPI:1750594735
Name:BLACK, AMIE MARION (LMT)
Entity type:Individual
Prefix:
First Name:AMIE
Middle Name:MARION
Last Name:BLACK
Suffix:
Gender:F
Credentials:LMT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 1476
Mailing Address - Street 2:
Mailing Address - City:LAKE ARROWHEAD
Mailing Address - State:CA
Mailing Address - Zip Code:92352-1476
Mailing Address - Country:US
Mailing Address - Phone:909-337-5928
Mailing Address - Fax:909-337-4027
Practice Address - Street 1:29099 HOSPITAL RD
Practice Address - Street 2:SUITE 103
Practice Address - City:LAKE ARROWHEAD
Practice Address - State:CA
Practice Address - Zip Code:92352-1476
Practice Address - Country:US
Practice Address - Phone:909-337-5928
Practice Address - Fax:909-337-4027
Is Sole Proprietor?:Yes
Enumeration Date:2007-05-07
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CACOB06240247200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes247200000XTechnologists, Technicians & Other Technical Service ProvidersTechnician, Other