Basic Information
| Provider Information | |||||||||
| NPI: | 1104206598 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | BLACK | ||||||||
| FirstName: | SANDRA | ||||||||
| MiddleName: | JUEL | ||||||||
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| Credential: | L.M.T. | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 371 | ||||||||
| Address2: | |||||||||
| City: | SHELL ROCK | ||||||||
| State: | IA | ||||||||
| PostalCode: | 506700371 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7734902259 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 2052 N CLEVELAND AVE | ||||||||
| Address2: | GARDEN SUITE | ||||||||
| City: | CHICAGO | ||||||||
| State: | IL | ||||||||
| PostalCode: | 606144505 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7732812225 | ||||||||
| FaxNumber: | 7732812226 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/01/2015 | ||||||||
| LastUpdateDate: | 06/01/2015 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 225700000X | 227.005112 | IL | Y | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Massage Therapist | 225700000X | 006290 | IA | N | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Massage Therapist |
No ID Information.