Healthcare Provider Details

I. General information

NPI: 1457499428
Provider Name (Legal Business Name): ROBERT GRANT BLACK PT
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 02/02/2007
Last Update Date: 08/20/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

285 VISTA DRIVE SUITE A
POCATELLO ID
83201
US

IV. Provider business mailing address

2176 E. FRANKLIN ROAD SUITE 100
MERIDIAN ID
83642-9024
US

V. Phone/Fax

Practice location:
  • Phone: 208-478-1488
  • Fax: 208-478-1498
Mailing address:
  • Phone: 208-288-1155
  • Fax: 208-288-0424

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code174400000X
TaxonomySpecialist
License NumberPT-1705
License Number StateID
# 2
Primary TaxonomyY
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License Number3435682401
License Number StateUT

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: