MEDICARE: GEORGIA BLACK

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	225200000X	Physical Therapy Assistant

General Provider Information

NPI Number	:	1750214268
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	GEORGIA BLACK

Provider Business Mailing Address
First Line	:	223 HICKORY ST
Second Line	:
City	:	PARADISE
State	:	TX
Zip	:	76073-2764
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	901 MEDICAL CENTER DR STE 100
Second Line	:
City	:	DECATUR
State	:	TX
Zip	:	76234-3874
Country	:	US
Telephone Number	:	940-290-0273
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	06/04/2026
Last Update Date	:	06/04/2026

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Directions to “ GEORGIA BLACK ” Practice Location

Language	Start Address	Practice Location

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