MEDICARE: BLACK'S CHIROPRACTIC CLINIC, INC.

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	111NN0400X	Neurology Chiropractor

General Provider Information

NPI Number	:	1326253006
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	BLACK'S CHIROPRACTIC CLINIC, INC.

Provider Business Mailing Address
First Line	:	510 N BROADWAY ST
Second Line	:
City	:	CLEVELAND
State	:	OK
Zip	:	74020-2206
Country	:	US
Telephone Number	:	918-358-3509
Fax Number	:	918-358-3026

Provider Business Practice Location Address
First Line	:	510 N BROADWAY ST
Second Line	:
City	:	CLEVELAND
State	:	OK
Zip	:	74020-2206
Country	:	US
Telephone Number	:	918-358-3509
Fax Number	:	918-358-3026

Authorized Official
Title or Position	:	PRESIDENT
Name	:	DR. ED J BLACK
Credential	:	D.C.
Telephone Number	:	918-358-3509

Provider Enumeration Date	:	05/14/2007
Last Update Date	:	08/24/2007

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