Individual
ROBERT GRANT BLACK
Active
Sole proprietor
No
Provider details
NPI number
Gender
Man
Credential
PT
Contact information
Practice address
285 VISTA DRIVE, SUITE A, POCATELLO, ID 83201
(208) 478-1488
(208) 478-1498
Mailing address
2176 E. FRANKLIN ROAD, SUITE 100, MERIDIAN, ID 83642-9024
(208) 288-1155
(208) 288-0424
Taxonomy
Speciality
Code
Description
License number
State
174400000X
Specialist
PT-1705
ID
225100000X
Physical Therapist
Primary
3435682401
UT
Other
Other identifiers
Code
Description
Identifier
Issuer
State
05
—
D4888
—
UT
Enumeration date
02/02/2007
Last updated
08/20/2008
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