Provider Demographics
NPI:1821898115
Name:BLACK, SANDRA KLEISER
Entity type:Individual
Prefix:
First Name:SANDRA
Middle Name:KLEISER
Last Name:BLACK
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:113 GOLDENGATE DR
Mailing Address - Street 2:
Mailing Address - City:CENTERVILLE
Mailing Address - State:OH
Mailing Address - Zip Code:45459-4326
Mailing Address - Country:US
Mailing Address - Phone:937-225-1481
Mailing Address - Fax:
Practice Address - Street 1:113 GOLDENGATE DR
Practice Address - Street 2:
Practice Address - City:CENTERVILLE
Practice Address - State:OH
Practice Address - Zip Code:45459-4326
Practice Address - Country:US
Practice Address - Phone:937-225-1481
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2025-03-15
Last Update Date:2025-05-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes374U00000XNursing Service Related ProvidersHome Health Aide
No172A00000XOther Service ProvidersDriver
No372600000XNursing Service Related ProvidersAdult Companion
No3747P1801XNursing Service Related ProvidersTechnicianPersonal Care Attendant