Provider Demographics
NPI:1376848572
Name:BLACK FOUNDATION
Entity Type:Organization
Organization Name:BLACK FOUNDATION
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:
Authorized Official - First Name:ROBERT
Authorized Official - Middle Name:
Authorized Official - Last Name:BRIDGES
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:310-210-0996
Mailing Address - Street 1:450 E SILVERADO RANCH BLVD # 200
Mailing Address - Street 2:
Mailing Address - City:LAS VEGAS
Mailing Address - State:NV
Mailing Address - Zip Code:89183-6203
Mailing Address - Country:US
Mailing Address - Phone:323-931-3211
Mailing Address - Fax:
Practice Address - Street 1:4571 W WASHINGTON BLVD
Practice Address - Street 2:
Practice Address - City:LOS ANGELES
Practice Address - State:CA
Practice Address - Zip Code:90016-1717
Practice Address - Country:US
Practice Address - Phone:323-931-3211
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-01-19
Last Update Date:2011-01-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAADP190249AN103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologistGroup - Single Specialty