Provider Demographics
NPI:1104252931
Name:BLACK, TINA ROXANNE (DC)
Entity type:Individual
Prefix:MS
First Name:TINA
Middle Name:ROXANNE
Last Name:BLACK
Suffix:
Gender:F
Credentials:DC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:664 SANGO RD.
Mailing Address - Street 2:
Mailing Address - City:CLARKSVILLE
Mailing Address - State:TN
Mailing Address - Zip Code:37043
Mailing Address - Country:US
Mailing Address - Phone:931-368-1996
Mailing Address - Fax:931-368-0448
Practice Address - Street 1:664 SANGO RD
Practice Address - Street 2:
Practice Address - City:CLARKSVILLE
Practice Address - State:TN
Practice Address - Zip Code:37043
Practice Address - Country:US
Practice Address - Phone:931-368-1996
Practice Address - Fax:931-368-0448
Is Sole Proprietor?:Yes
Enumeration Date:2013-09-25
Last Update Date:2013-09-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TNDC0000001775111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor