1821499104 NPI number — BLACK FAMILY AND CHILD SERVICES INC

Table of Contents

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1821499104 NPI number — BLACK FAMILY AND CHILD SERVICES INC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
BLACK FAMILY AND CHILD SERVICES INC
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:
1821499104
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
09/05/2014
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
1522 E SOUTHERN AVE
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
PHOENIX
Provider Business Mailing Address State Name:
AZ
Provider Business Mailing Address Postal Code:
85040-3543
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
602-243-1773
Provider Business Mailing Address Fax Number:
602-276-1984

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
11120 W VAN BUREN ST APT 2117
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
AVONDALE
Provider Business Practice Location Address State Name:
AZ
Provider Business Practice Location Address Postal Code:
85323-7304
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
602-243-1773
Provider Business Practice Location Address Fax Number:
602-276-1984
Provider Enumeration Date:
09/05/2014

Additional Information

Authorized Official

Authorized Official Last Name:
BLACK
Authorized Official First Name:
MARY
Authorized Official Middle Name:
M
Authorized Official Title or Position:
CHIEF EXECUTIVE OFFICER
Authorized Official Telephone Number:
602-243-1773

Provider Taxonomy Codes

  • Taxonomy code: 251S00000X , with the licence number:  4868156 , registered in the state of AZ ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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





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