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General NPI Number Information
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NPI Number | 1750594735
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Entity Type | Individual
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Provider Name | AMIE MARION BLACK LMT
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Gender | Female
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Dates
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Enumeration Date | 05/07/2007
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Last Update Date | 07/08/2007
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Provider Practice Location Address
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Address Line | 29099 HOSPITAL RD SUITE 103
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City | LAKE ARROWHEAD
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State | CA
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Zip | 92352-1476
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Country | US
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Telephone | 909-337-5928
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Fax | 909-337-4027
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Provider Business Mailing Address
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Address Line | PO BOX 1476
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City | LAKE ARROWHEAD
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State | CA
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Zip | 92352-1476
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Country | US
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Telephone | 909-337-5928
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Fax | 909-337-4027
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 247200000X
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Taxonomy Name | Other Technician
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License Number | COB06240
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License Number State | CA
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