Individual
DR. JAY CHARLES BLACK
Active
Sole proprietor
No
Provider details
NPI number
Gender
Man
Credential
OD
Contact information
Practice address
5316 N SECOND STREET, LOVES PARK, IL 61111-5009
(815) 877-6551
(815) 877-4821
Mailing address
5316 N SECOND STREET, LOVES PARK, IL 61111-5009
(815) 877-6551
(815) 877-4821
Taxonomy
Speciality
Code
Description
License number
State
152W00000X
Optometrist
Primary
466709
IL
Other
Other identifiers
Code
Description
Identifier
Issuer
State
01
—
362871342
FED ID NUMBER
IL
Enumeration date
02/21/2007
Last updated
07/08/2007
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