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General NPI Number Information
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NPI Number | 1568861037
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Entity Type | Organization
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Legal Business Name | BLACK HOLDINGS GROUP,LLC
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Dates
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Enumeration Date | 08/20/2014
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Last Update Date | 08/20/2014
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Provider Practice Location Address
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Address Line | 8000 CENTERVIEW PKWY SUITE 104
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City | CORDOVA
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State | TN
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Zip | 38018-4227
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Country | US
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Telephone | 901-755-6280
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Fax | 901-755-7897
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Provider Business Mailing Address
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Address Line | PO BOX 38175
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City | GERMANTOWN
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State | TN
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Zip | 38183-0175
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Country | US
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Telephone | 901-755-6280
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Fax | 901-755-7897
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Authorized Official
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Title or Position | PHYSICIAN
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Name | DR. AUDRIA KAYE BLACK
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Credential | MD
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Telephone | 901-755-6280
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 261QM0850X
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Taxonomy Name | Adult Mental Health Clinic/Center
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License Number | 36627
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License Number State | TN
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Taxonomy #2
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Taxonomy Code | 261QM0855X
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Taxonomy Name | Adolescent and Children Mental Health Clinic/Center
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License Number | 36627
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License Number State | TN
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