MEDICARE: MRS. ABBY BLACK RD, CDE

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	875262

General Provider Information

NPI Number	:	1750631511
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MRS. ABBY BLACK RD, CDE

Provider Business Mailing Address
First Line	:	717 SAINT JOSEPH DR
Second Line	:	STE 140
City	:	SAINT JOSEPH
State	:	MI
Zip	:	49085-2428
Country	:	US
Telephone Number	:	269-369-2347
Fax Number	:

Provider Business Practice Location Address
First Line	:	511 RENAISSANCE DR
Second Line	:	SUITE 130
City	:	SAINT JOSEPH
State	:	MI
Zip	:	49085-2180
Country	:	US
Telephone Number	:	269-350-9789
Fax Number	:

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

Provider Enumeration Date	:	09/19/2012
Last Update Date	:	10/31/2016

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