Provider Demographics
NPI:1053558684
Name:BLACK, JAMES (PTA)
Entity type:Individual
Prefix:
First Name:JAMES
Middle Name:
Last Name:BLACK
Suffix:
Gender:M
Credentials:PTA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:213 CALIFORNIA STREET
Mailing Address - Street 2:
Mailing Address - City:MISSION VIEJO
Mailing Address - State:CA
Mailing Address - Zip Code:92692
Mailing Address - Country:US
Mailing Address - Phone:949-305-9446
Mailing Address - Fax:
Practice Address - Street 1:213 CALIFORNIA CT
Practice Address - Street 2:
Practice Address - City:MISSION VIEJO
Practice Address - State:CA
Practice Address - Zip Code:92692-4082
Practice Address - Country:US
Practice Address - Phone:949-305-9446
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2009-01-20
Last Update Date:2009-01-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA3319225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant