MEDICARE: AFRICAN AMERICAN FAMILY SERVICES

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	251S00000X	Community/Behavioral Health Agency	805976-2-CDT	MN

General Provider Information

NPI Number	:	1609043124
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	AFRICAN AMERICAN FAMILY SERVICES

Provider Business Mailing Address
First Line	:	1041 SELBY AVE
Second Line	:
City	:	SAINT PAUL
State	:	MN
Zip	:	55104-6535
Country	:	US
Telephone Number	:	651-642-0021
Fax Number	:	651-642-0043

Provider Business Practice Location Address
First Line	:	1041 SELBY AVE
Second Line	:
City	:	SAINT PAUL
State	:	MN
Zip	:	55104-6535
Country	:	US
Telephone Number	:	651-642-0021
Fax Number	:	651-642-0043

Authorized Official
Title or Position	:	EXECUTIVE DIRECTOR
Name	:	MS. LISSA JONES
Credential	:
Telephone Number	:	612-871-7878

Provider Enumeration Date	:	05/14/2008
Last Update Date	:	05/14/2008

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