Organization
CHARLES L. BLACK JR MD SURGICAL CLINIC CORP
Active
Organization subpart
No
Provider details
NPI number
Authorized official
CHARLES LESTER BLACK JR. M.D. (OWNER)
(318) 221-0166
Entity
Organization
Contact information
Practice address
1534 ELIZABETH AVE, SUITE 202, SHREVEPORT, LA 71101-4516
(318) 221-0166
Mailing address
1534 ELIZABETH AVE, SUITE 202, SHREVEPORT, LA 71101-4516
(318) 221-0166
Taxonomy
Speciality
Code
Description
License number
State
208600000X
Surgery Physician
Primary
011576
LA
Other
Other identifiers
Code
Description
Identifier
Issuer
State
05
—
1169838
—
LA
Enumeration date
02/12/2007
Last updated
09/14/2007
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