Provider Demographics
NPI:1215076997
Name:OBLACK, DARRYL ALBERT (DC)
Entity type:Individual
Prefix:DR
First Name:DARRYL
Middle Name:ALBERT
Last Name:OBLACK
Suffix:
Gender:M
Credentials:DC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:510 BAXTER RD
Mailing Address - Street 2:SUITE 4S
Mailing Address - City:CHESTERFIELD
Mailing Address - State:MO
Mailing Address - Zip Code:63017-7032
Mailing Address - Country:US
Mailing Address - Phone:636-227-6336
Mailing Address - Fax:636-227-9878
Practice Address - Street 1:510 BAXTER RD
Practice Address - Street 2:SUITE 4S
Practice Address - City:CHESTERFIELD
Practice Address - State:MO
Practice Address - Zip Code:63017-7032
Practice Address - Country:US
Practice Address - Phone:636-227-6336
Practice Address - Fax:636-227-9878
Is Sole Proprietor?:Yes
Enumeration Date:2007-02-06
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MOCE006385111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
MOU58989Medicare UPIN