=====================================================
General NPI Number Information
=====================================================
NPI Number | 1083745756
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | BLACK & ASSOCIATES GLOBAL INC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 03/07/2007
-----------------------------------------------------
Last Update Date | 07/07/2008
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 408 ANDREW ST
-----------------------------------------------------
City | GREENSBORO
-----------------------------------------------------
State | NC
-----------------------------------------------------
Zip | 27406-1515
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 336-271-2004
-----------------------------------------------------
Fax | 336-454-0191
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 102 BURROWS RD
-----------------------------------------------------
City | JAMESTOWN
-----------------------------------------------------
State | NC
-----------------------------------------------------
Zip | 27282-8400
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 336-987-0572
-----------------------------------------------------
Fax | 336-454-0191
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | ADMINISTRATOR
-----------------------------------------------------
Name | MRS. ELLEN ROGERS BLACK
-----------------------------------------------------
Credential | OWNER
-----------------------------------------------------
Telephone | 336-987-0572
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 320900000X
-----------------------------------------------------
Taxonomy Name | Intellectual and/or Developmental Disabilities Community Based Residential Treatment Facility
-----------------------------------------------------
License Number | MHL 041-781
-----------------------------------------------------
License Number State | NC
-----------------------------------------------------