MEDICARE: EBONY HOUSE 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	324500000X	Substance Abuse Rehabilitation Facility	BH076	AZ

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	319790	OTHER	AZ	AHCCCS NUMBER

General Provider Information

NPI Number	:	1023170933
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	EBONY HOUSE INC

Provider Business Mailing Address
First Line	:	6222 S 13TH ST
Second Line	:
City	:	PHOENIX
State	:	AZ
Zip	:	85042-4408
Country	:	US
Telephone Number	:	602-276-4288
Fax Number	:	602-232-2938

Provider Business Practice Location Address
First Line	:	6218 S 13TH ST
Second Line	:
City	:	PHOENIX
State	:	AZ
Zip	:	85042-4408
Country	:	US
Telephone Number	:	602-276-4288
Fax Number	:	602-232-2938

Authorized Official
Title or Position	:	CEO
Name	:	CHE JORDAN
Credential	:
Telephone Number	:	602-276-4288

Provider Enumeration Date	:	12/15/2006
Last Update Date	:	07/26/2023

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Directions to “EBONY HOUSE INC ” Practice Location

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