Healthcare Provider Details

I. General information

NPI: 1003678822
Provider Name (Legal Business Name): RODNEY WAYNE BLACK
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 01/26/2024
Last Update Date: 01/26/2024
Certification Date: 01/26/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6300 EHRHARDT AVE
SACRAMENTO CA
95823-5637
US

IV. Provider business mailing address

6300 EHRHARDT AVE
SACRAMENTO CA
95823-5637
US

V. Phone/Fax

Practice location:
  • Phone: 916-718-3626
  • Fax:
Mailing address:
  • Phone: 916-718-3626
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code251B00000X
TaxonomyCase Management Agency
License Number
License Number StateNULL
# 2
Primary TaxonomyY
Taxonomy Code172V00000X
TaxonomyCommunity Health Worker
License Number
License Number StateNULL
# 3
Primary TaxonomyN
Taxonomy Code171M00000X
TaxonomyCase Manager/Care Coordinator
License Number
License Number StateNULL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: