Provider Demographics
NPI:1538434097
Name:BLACK, ROBERT CLINT (RN)
Entity type:Individual
Prefix:
First Name:ROBERT
Middle Name:CLINT
Last Name:BLACK
Suffix:
Gender:M
Credentials:RN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1169 BRODERICK RD
Mailing Address - Street 2:
Mailing Address - City:OMRO
Mailing Address - State:WI
Mailing Address - Zip Code:54963-1091
Mailing Address - Country:US
Mailing Address - Phone:240-603-3648
Mailing Address - Fax:
Practice Address - Street 1:1169 BRODERICK RD
Practice Address - Street 2:
Practice Address - City:OMRO
Practice Address - State:WI
Practice Address - Zip Code:54963-1091
Practice Address - Country:US
Practice Address - Phone:240-603-3648
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-03-16
Last Update Date:2012-03-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI162432-30163W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163W00000XNursing Service ProvidersRegistered Nurse