=====================================================
General NPI Number Information
=====================================================
NPI Number | 1689971715
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | BLACK CHIROPRACTIC PC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 02/25/2011
-----------------------------------------------------
Last Update Date | 02/25/2011
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1609 SHERMAN AVE 204
-----------------------------------------------------
City | EVANSTON
-----------------------------------------------------
State | IL
-----------------------------------------------------
Zip | 60201-3753
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 847-328-2008
-----------------------------------------------------
Fax | 847-328-8171
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 1609 SHERMAN AVE 204
-----------------------------------------------------
City | EVANSTON
-----------------------------------------------------
State | IL
-----------------------------------------------------
Zip | 60201-3753
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 847-328-2008
-----------------------------------------------------
Fax | 847-328-8171
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | PRESIDENT
-----------------------------------------------------
Name | CONSTANCE A BLACK
-----------------------------------------------------
Credential | D.C.
-----------------------------------------------------
Telephone | 847-328-2008
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 111N00000X
-----------------------------------------------------
Taxonomy Name | Chiropractor
-----------------------------------------------------
License Number | 038003757
-----------------------------------------------------
License Number State | IL
-----------------------------------------------------