Provider Demographics
NPI:1730185794
Name:BLACK, CARL ROBERT (DC)
Entity type:Individual
Prefix:DR
First Name:CARL
Middle Name:ROBERT
Last Name:BLACK
Suffix:
Gender:M
Credentials:DC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:502 1ST AVE SE
Mailing Address - Street 2:DR C R BLACK
Mailing Address - City:LAMOURE
Mailing Address - State:ND
Mailing Address - Zip Code:58458-7109
Mailing Address - Country:US
Mailing Address - Phone:701-883-5973
Mailing Address - Fax:
Practice Address - Street 1:502 1ST AVE SE
Practice Address - Street 2:
Practice Address - City:LAMOURE
Practice Address - State:ND
Practice Address - Zip Code:58458-7109
Practice Address - Country:US
Practice Address - Phone:701-883-4276
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2005-06-23
Last Update Date:2019-04-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ND834111N00000X
SD658111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
SD7602370Medicaid
ND10402Medicaid
SD7602370Medicaid
ND10402Medicaid
SD86523Medicare ID - Type Unspecified