Provider Demographics
NPI:1154357242
Name:BLACK, MARSHALL R (CPO)
Entity type:Individual
Prefix:
First Name:MARSHALL
Middle Name:R
Last Name:BLACK
Suffix:
Gender:M
Credentials:CPO
Other - Prefix:
Other - First Name:MARSHALL
Other - Middle Name:R
Other - Last Name:BLACK
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:CPO
Mailing Address - Street 1:823 16TH AVE
Mailing Address - Street 2:
Mailing Address - City:LEWISTON
Mailing Address - State:ID
Mailing Address - Zip Code:83501-3733
Mailing Address - Country:US
Mailing Address - Phone:208-798-0200
Mailing Address - Fax:208-798-0201
Practice Address - Street 1:823 16TH AVE
Practice Address - Street 2:
Practice Address - City:LEWISTON
Practice Address - State:ID
Practice Address - Zip Code:83501-3733
Practice Address - Country:US
Practice Address - Phone:208-798-0200
Practice Address - Fax:208-798-0201
Is Sole Proprietor?:Yes
Enumeration Date:2006-06-23
Last Update Date:2007-11-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes222Z00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOrthotist
No224P00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersProsthetist
Provider Identifiers
StateIdentifier IDID TypeIssuer
ID5792320001Medicare NSC