Healthcare Provider Details

I. General information

NPI: 1194726604
Provider Name (Legal Business Name): DANIEL T BLACK DO
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/09/2005
Last Update Date: 09/12/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

108 GRIFFITH ST
SALE CREEK TN
37373-9715
US

IV. Provider business mailing address

PO BOX 667 108 GRIFFITH ST
SALE CREEK TN
37373-0667
US

V. Phone/Fax

Practice location:
  • Phone: 423-332-1813
  • Fax: 423-332-7732
Mailing address:
  • Phone: 423-332-1813
  • Fax: 423-332-7732

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License NumberDO1671
License Number StateTN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: