Basic Information
| Provider Information | |||||||||
| NPI: | 1982841128 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | BLACK | ||||||||
| FirstName: | ALAN | ||||||||
| MiddleName: | D | ||||||||
| NamePrefix: | MR. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 650 JOEL DRIVE | ||||||||
| Address2: | BACH-YEC | ||||||||
| City: | FT CAMPBELL | ||||||||
| State: | KY | ||||||||
| PostalCode: | 42223 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2707988258 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 650 JOEL DRIVE | ||||||||
| Address2: | BACH-YEC | ||||||||
| City: | FT CAMPBELL | ||||||||
| State: | KY | ||||||||
| PostalCode: | 42223 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2707988258 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 01/09/2009 | ||||||||
| LastUpdateDate: | 01/09/2009 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 164W00000X | 2040679 | KY | Y | Nursing Service Providers | Licensed Practical Nurse |
No ID Information.