Provider Demographics
NPI:1548272800
Name:BLACK, DAVID A (DC)
Entity type:Individual
Prefix:MR
First Name:DAVID
Middle Name:A
Last Name:BLACK
Suffix:
Gender:M
Credentials:DC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
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Other - Credentials:
Mailing Address - Street 1:19501 E US HIGHWAY 40
Mailing Address - Street 2:SUITE B
Mailing Address - City:INDEPENDENCE
Mailing Address - State:MO
Mailing Address - Zip Code:64055-5463
Mailing Address - Country:US
Mailing Address - Phone:816-795-5000
Mailing Address - Fax:816-795-5001
Practice Address - Street 1:19501 E US HIGHWAY 40
Practice Address - Street 2:SUITE B
Practice Address - City:INDEPENDENCE
Practice Address - State:MO
Practice Address - Zip Code:64055-5463
Practice Address - Country:US
Practice Address - Phone:816-795-5000
Practice Address - Fax:816-795-5001
Is Sole Proprietor?:No
Enumeration Date:2006-08-13
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2001002825111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO7782255OtherAETNA
MO83468OtherCOVENTRY
MO4400406OtherUNITED HEALTHCARE
MO29405015OtherBLUE CROSS BLUE SHIELD KC
MO83468OtherCOVENTRY
E46A951Medicare ID - Type Unspecified