MEDICARE: BLACK FAMILY AND CHILD SERVICES INC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	251S00000X	Community/Behavioral Health Agency	4868156	AZ

General Provider Information

NPI Number	:	1821499104
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	BLACK FAMILY AND CHILD SERVICES INC

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

Provider Business Practice Location Address
First Line	:	11120 W VAN BUREN ST APT 2117
Second Line	:
City	:	AVONDALE
State	:	AZ
Zip	:	85323-7304
Country	:	US
Telephone Number	:	602-243-1773
Fax Number	:	602-276-1984

Authorized Official
Title or Position	:	CHIEF EXECUTIVE OFFICER
Name	:	MS. MARY M BLACK
Credential	:
Telephone Number	:	602-243-1773

Provider Enumeration Date	:	09/05/2014
Last Update Date	:	09/05/2014

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