Provider Demographics
NPI:1164264230
Name:BLACK, VAN ALLEN JR
Entity type:Individual
Prefix:
First Name:VAN
Middle Name:ALLEN
Last Name:BLACK
Suffix:JR
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:40925 COUNTY CENTER DR
Mailing Address - Street 2:
Mailing Address - City:TEMECULA
Mailing Address - State:CA
Mailing Address - Zip Code:92591-6054
Mailing Address - Country:US
Mailing Address - Phone:951-305-2944
Mailing Address - Fax:
Practice Address - Street 1:40925 COUNTY CENTER DR
Practice Address - Street 2:
Practice Address - City:TEMECULA
Practice Address - State:CA
Practice Address - Zip Code:92591-6054
Practice Address - Country:US
Practice Address - Phone:951-600-6300
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-06-10
Last Update Date:2024-06-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171M00000XOther Service ProvidersCase Manager/Care Coordinator