Basic Information
| Provider Information | |||||||||
| NPI: | 1689632838 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | BLACK BELT MEDICAL INC. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 7856 WESTSIDE PARK DR | ||||||||
| Address2: | SUITE C | ||||||||
| City: | MOBILE | ||||||||
| State: | AL | ||||||||
| PostalCode: | 366958541 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2516338090 | ||||||||
| FaxNumber: | 2516336941 | ||||||||
| Practice Location | |||||||||
| Address1: | 1004 JEFF DAVIS AVE | ||||||||
| Address2: | |||||||||
| City: | SELMA | ||||||||
| State: | AL | ||||||||
| PostalCode: | 367014519 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3348729721 | ||||||||
| FaxNumber: | 3348744923 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/03/2006 | ||||||||
| LastUpdateDate: | 03/27/2008 | ||||||||
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| AuthorizedOfficialLastName: | CARL | ||||||||
| AuthorizedOfficialFirstName: | JERRY | ||||||||
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| AuthorizedOfficialTitleorPosition: | CEO/PRESIDENT | ||||||||
| AuthorizedOfficialTelephone: | 2516338090 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNameSuffix: | JR. | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 332B00000X | Y | Suppliers | Durable Medical Equipment & Medical Supplies |
ID Information
| ID | Type | State | Issuer | Description | 51516028 | 01 | AL | BLUE CROSS BLUE SHIELD | OTHER |