Healthcare Provider Details

I. General information

NPI: 1154357242
Provider Name (Legal Business Name): MARSHALL R BLACK CPO
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

Provider Other Name: MARSHALL R BLACK CPO

II. Dates (important events)

Enumeration Date: 06/23/2006
Last Update Date: 11/02/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

823 16TH AVE
LEWISTON ID
83501-3733
US

IV. Provider business mailing address

823 16TH AVE
LEWISTON ID
83501-3733
US

V. Phone/Fax

Practice location:
  • Phone: 208-798-0200
  • Fax: 208-798-0201
Mailing address:
  • Phone: 208-798-0200
  • Fax: 208-798-0201

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code222Z00000X
TaxonomyOrthotist
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code224P00000X
TaxonomyProsthetist
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: