1679140040 NPI number — THE BLACK MENTAL HEALTH CORPORATION

Table of content: (NPI 1679140040)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1679140040 NPI number — THE BLACK MENTAL HEALTH CORPORATION

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
THE BLACK MENTAL HEALTH CORPORATION
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1679140040
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
06/05/2021
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
4531 EMERSON RD
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
SOUTH EUCLID
Provider Business Mailing Address State Name:
OH
Provider Business Mailing Address Postal Code:
44121-3929
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
330-518-4863
Provider Business Mailing Address Fax Number:
216-370-3192

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
13110 SHAKER SQ STE C200
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
CLEVELAND
Provider Business Practice Location Address State Name:
OH
Provider Business Practice Location Address Postal Code:
44120-2373
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
216-512-0321
Provider Business Practice Location Address Fax Number:
216-370-3192
Provider Enumeration Date:
06/05/2021

Additional Information

Authorized Official

Authorized Official Last Name:
YANAMAYU
Authorized Official First Name:
DESMOND
Authorized Official Middle Name:
EUGENE
Authorized Official Title or Position:
CLINICAL DIRECTOR
Authorized Official Telephone Number:
330-518-4863

Provider Taxonomy Codes

  • Taxonomy code: 101YA0400X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 0443172 , issued by the state of ( OH ) . This identifiers is of the category "MEDICAID".




Copyright © 2007-2024 www.npivalidator.com