Provider Demographics
NPI:1982841128
Name:BLACK, ALAN D
Entity type:Individual
Prefix:MR
First Name:ALAN
Middle Name:D
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 1:650 JOEL DRIVE
Mailing Address - Street 2:BACH-YEC
Mailing Address - City:FT CAMPBELL
Mailing Address - State:KY
Mailing Address - Zip Code:42223
Mailing Address - Country:US
Mailing Address - Phone:270-798-8258
Mailing Address - Fax:
Practice Address - Street 1:650 JOEL DRIVE
Practice Address - Street 2:BACH-YEC
Practice Address - City:FT CAMPBELL
Practice Address - State:KY
Practice Address - Zip Code:42223
Practice Address - Country:US
Practice Address - Phone:270-798-8258
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2009-01-09
Last Update Date:2009-01-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY2040679164W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164W00000XNursing Service ProvidersLicensed Practical Nurse