Healthcare Provider Details

I. General information

NPI: 1518026012
Provider Name (Legal Business Name): LEWIS ADAMSON BLACK DC
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/08/2006
Last Update Date: 03/07/2022
Certification Date: 03/07/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1478 EAST HIGHWAY 162
MONTEZUMA CREEK UT
84534
US

IV. Provider business mailing address

PO BOX 130
MONTEZUMA CREEK UT
84534-0130
US

V. Phone/Fax

Practice location:
  • Phone: 435-651-3700
  • Fax: 435-678-0608
Mailing address:
  • Phone: 435-651-3700
  • Fax: 435-678-0608

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code111N00000X
TaxonomyChiropractor
License Number4723
License Number StateCO
# 2
Primary TaxonomyY
Taxonomy Code111N00000X
TaxonomyChiropractor
License Number7693068-1202
License Number StateUT

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: