1720645724 NPI number — BENJAMIN DAVIS BLACK D.C.

Table of content: MRS. ALEESHA BRIESEMEISTER PHARM.D. (NPI 1851723415)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1720645724 NPI number — BENJAMIN DAVIS BLACK D.C.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
BLACK
Provider First Name:
BENJAMIN
Provider Middle Name:
DAVIS
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
D.C.
Provider Gender Code:
M

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
BLACK
Provider Other First Name:
BEN
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
D.C.
Provider Other Last Name Type Code:
2

NPI Number Information

NPI Number:
1720645724
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
05/24/2019
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
19850 OLD SCENIC HWY STE 400
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
ZACHARY
Provider Business Mailing Address State Name:
LA
Provider Business Mailing Address Postal Code:
70791-7384
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
225-570-8404
Provider Business Mailing Address Fax Number:
225-570-8406

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
14395 GREENWELL SPRINGS RD STE A
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
GREENWELL SPRINGS
Provider Business Practice Location Address State Name:
LA
Provider Business Practice Location Address Postal Code:
70739-3340
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
225-570-8404
Provider Business Practice Location Address Fax Number:
225-570-8406
Provider Enumeration Date:
05/24/2019

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: 111N00000X , with the licence number:  1868 , registered in the state of LA ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 1868 . This is a "STATE LICENSE" identifier , issued by the state of ( LA ) . This identifiers is of the category "OTHER".




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