Healthcare Provider Details

I. General information

NPI: 1295814903
Provider Name (Legal Business Name): ADAM C. BLACK OD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/03/2006
Last Update Date: 10/10/2024
Certification Date: 10/10/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

232 S WASHINGTON ST STE 3
NAPERVILLE IL
60540-5370
US

IV. Provider business mailing address

232 S WASHINGTON ST STE 3
NAPERVILLE IL
60540-5370
US

V. Phone/Fax

Practice location:
  • Phone: 630-369-3937
  • Fax: 630-369-3933
Mailing address:
  • Phone: 630-369-3937
  • Fax: 630-369-3933

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code152W00000X
TaxonomyOptometrist
License Number2536
License Number StateCO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: