MEDICARE: DR. BRANDON DUSTIN BLACK D.C.

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	111N00000X	Chiropractor	11260	TX

General Provider Information

NPI Number	:	1053544650
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. BRANDON DUSTIN BLACK D.C.

Provider Business Mailing Address
First Line	:	820 S MACARTHUR BLVD
Second Line	:	SUITE 105-127
City	:	COPPELL
State	:	TX
Zip	:	75019-4216
Country	:	US
Telephone Number	:	469-323-3909
Fax Number	:

Provider Business Practice Location Address
First Line	:	2928 INWOOD RD
Second Line	:
City	:	DALLAS
State	:	TX
Zip	:	75235-7518
Country	:	US
Telephone Number	:	469-323-3909
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	08/29/2009
Last Update Date	:	09/02/2009

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