Healthcare Provider Details

I. General information

NPI: 1639293087
Provider Name (Legal Business Name): EDDIE J BLACK D.C.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/19/2007
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

510 N BROADWAY ST
CLEVELAND OK
74020-2206
US

IV. Provider business mailing address

510 N BROADWAY ST
CLEVELAND OK
74020-2206
US

V. Phone/Fax

Practice location:
  • Phone: 918-358-3509
  • Fax: 918-358-3026
Mailing address:
  • Phone: 918-358-3509
  • Fax: 918-358-3026

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code111NN0400X
TaxonomyNeurology Chiropractor
License Number1611
License Number StateOK

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: