=====================================================
General NPI Number Information
=====================================================
NPI Number | 1992032213
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | EBONY GROUP INCORPORATED
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 11/06/2009
-----------------------------------------------------
Last Update Date | 11/06/2009
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 522 W 127TH ST STE 313
-----------------------------------------------------
City | LOS ANGELES
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 90044-7002
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 323-418-1620
-----------------------------------------------------
Fax | 323-418-1620
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 522 W 127TH ST STE 313
-----------------------------------------------------
City | LOS ANGELES
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 90044-7002
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 323-418-1620
-----------------------------------------------------
Fax | 323-418-1620
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | MANAGING DIRECTOR
-----------------------------------------------------
Name | MR. TONY UMUNNA EBO
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 562-221-9929
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 251B00000X
-----------------------------------------------------
Taxonomy Name | Case Management Agency
-----------------------------------------------------
License Number | 3191112
-----------------------------------------------------
License Number State | CA
-----------------------------------------------------