Provider Demographics
NPI:1073358792
Name:BLACK, JAMES PAUL
Entity type:Individual
Prefix:
First Name:JAMES
Middle Name:PAUL
Last Name:BLACK
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:33979 LILY RD # 92
Mailing Address - Street 2:
Mailing Address - City:YUCAIPA
Mailing Address - State:CA
Mailing Address - Zip Code:92399-2287
Mailing Address - Country:US
Mailing Address - Phone:714-872-3970
Mailing Address - Fax:
Practice Address - Street 1:11374 MOUNTAIN VIEW AVE STE A
Practice Address - Street 2:
Practice Address - City:LOMA LINDA
Practice Address - State:CA
Practice Address - Zip Code:92354-3816
Practice Address - Country:US
Practice Address - Phone:909-558-6715
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-06-25
Last Update Date:2024-06-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes172V00000XOther Service ProvidersCommunity Health Worker