Provider Demographics
NPI:1720154511
Name:BLACK, WAYNE EUGENE (NMD)
Entity type:Individual
Prefix:DR
First Name:WAYNE
Middle Name:EUGENE
Last Name:BLACK
Suffix:
Gender:M
Credentials:NMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1010 KELLEY RD
Mailing Address - Street 2:
Mailing Address - City:COLUMBIA FALLS
Mailing Address - State:MT
Mailing Address - Zip Code:59912-9185
Mailing Address - Country:US
Mailing Address - Phone:602-510-8789
Mailing Address - Fax:
Practice Address - Street 1:1010 KELLEY RD
Practice Address - Street 2:
Practice Address - City:COLUMBIA FALLS
Practice Address - State:MT
Practice Address - Zip Code:59912-9185
Practice Address - Country:US
Practice Address - Phone:602-510-8789
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-11-26
Last Update Date:2025-01-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MT2327175F00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes175F00000XOther Service ProvidersNaturopath