Healthcare Provider Details

I. General information

NPI: 1689374415
Provider Name (Legal Business Name): KAYLA BLACK
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 03/09/2023
Last Update Date: 03/09/2023
Certification Date: 03/09/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

7712 BANNOCKBURN TRL
COLORADO SPRINGS CO
80908-4845
US

IV. Provider business mailing address

7712 BANNOCKBURN TRL
COLORADO SPRINGS CO
80908-4845
US

V. Phone/Fax

Practice location:
  • Phone: 832-922-2414
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code133N00000X
TaxonomyNutritionist
License Number
License Number StateTX

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: