Provider Demographics
NPI:1568861037
Name:BLACK HOLDINGS GROUP,LLC
Entity Type:Organization
Organization Name:BLACK HOLDINGS GROUP,LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PHYSICIAN
Authorized Official - Prefix:DR
Authorized Official - First Name:AUDRIA
Authorized Official - Middle Name:KAYE
Authorized Official - Last Name:BLACK
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:901-755-6280
Mailing Address - Street 1:PO BOX 38175
Mailing Address - Street 2:
Mailing Address - City:GERMANTOWN
Mailing Address - State:TN
Mailing Address - Zip Code:38183-0175
Mailing Address - Country:US
Mailing Address - Phone:901-755-6280
Mailing Address - Fax:901-755-7897
Practice Address - Street 1:8000 CENTERVIEW PKWY
Practice Address - Street 2:SUITE 104
Practice Address - City:CORDOVA
Practice Address - State:TN
Practice Address - Zip Code:38018-4227
Practice Address - Country:US
Practice Address - Phone:901-755-6280
Practice Address - Fax:901-755-7897
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-08-20
Last Update Date:2014-08-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN36627261QM0850X, 261QM0855X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QM0855XAmbulatory Health Care FacilitiesClinic/CenterAdolescent and Children Mental Health
No261QM0850XAmbulatory Health Care FacilitiesClinic/CenterAdult Mental Health