MEDICARE: MARY M BLACK

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	133V00000X	Registered Dietitian	L000588	NC

General Provider Information

NPI Number	:	1407855034
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MARY M BLACK

Provider Business Mailing Address
First Line	:	300 W 27TH ST
Second Line	:	ATTN: WILLIAM J GUTEKUNST
City	:	LUMBERTON
State	:	NC
Zip	:	28358-3075
Country	:	US
Telephone Number	:	910-671-5000
Fax Number	:

Provider Business Practice Location Address
First Line	:	4300 FAYETTEVILLE RD
Second Line	:
City	:	LUMBERTON
State	:	NC
Zip	:	28358-2677
Country	:	US
Telephone Number	:	910-671-5830
Fax Number	:

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

Provider Enumeration Date	:	07/15/2005
Last Update Date	:	07/08/2007

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