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General NPI Number Information
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NPI Number | 1376848572
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Entity Type | Organization
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Legal Business Name | BLACK FOUNDATION
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Dates
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Enumeration Date | 01/19/2011
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Last Update Date | 01/19/2011
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Provider Practice Location Address
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Address Line | 4571 W WASHINGTON BLVD
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City | LOS ANGELES
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State | CA
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Zip | 90016-1717
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Country | US
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Telephone | 323-931-3211
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Fax |
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Provider Business Mailing Address
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Address Line | 450 E SILVERADO RANCH BLVD # 200
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City | LAS VEGAS
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State | NV
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Zip | 89183-6203
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Country | US
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Telephone | 323-931-3211
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Fax |
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Authorized Official
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Title or Position | CEO
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Name | ROBERT BRIDGES
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Credential |
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Telephone | 310-210-0996
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 103T00000X
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Taxonomy Name | Psychologist
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License Number | ADP190249AN
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License Number State | CA
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