Healthcare Provider Details

I. General information

NPI: 1336043470
Provider Name (Legal Business Name): XAVIER BLACK LMT
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/05/2026
Last Update Date: 10/05/2026
Certification Date: 10/03/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

112 SUNCHASER DR
COLUMBIA SC
29229-7307
US

IV. Provider business mailing address

112 SUNCHASER DR
COLUMBIA SC
29229-7307
US

V. Phone/Fax

Practice location:
  • Phone: 803-807-3003
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225700000X
TaxonomyMassage Therapist
License Number14521
License Number StateSC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: