1184818601 NPI number — DR. JILL DIANE BLACK PT, DPT, EDD

Table of content: DR. JILL DIANE BLACK PT, DPT, EDD (NPI 1184818601)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1184818601 NPI number — DR. JILL DIANE BLACK PT, DPT, EDD

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
BLACK
Provider First Name:
JILL
Provider Middle Name:
DIANE
Provider Name Prefix Text:
DR.
Provider Name Suffix Text:
Provider Credential Text:
PT, DPT, EDD
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
LATTANZI
Provider Other First Name:
JILL
Provider Other Middle Name:
BLACK
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:
1

NPI Number Information

NPI Number:
1184818601
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
07/03/2014
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
701 SAVANNAH RD
Provider Second Line Business Mailing Address:
A-1
Provider Business Mailing Address City Name:
LEWES
Provider Business Mailing Address State Name:
DE
Provider Business Mailing Address Postal Code:
19958-1550
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
302-644-2530
Provider Business Mailing Address Fax Number:
302-644-2556

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
701 SAVANNAH RD
Provider Second Line Business Practice Location Address:
A-1
Provider Business Practice Location Address City Name:
LEWES
Provider Business Practice Location Address State Name:
DE
Provider Business Practice Location Address Postal Code:
19958-1550
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
302-644-2530
Provider Business Practice Location Address Fax Number:
302-644-2556
Provider Enumeration Date:
08/28/2007

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 225100000X , with the licence number:  J10000513 , registered in the state of DE ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 1184818601 , issued by the state of ( DE ) . This identifiers is of the category "MEDICAID".




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