Provider Demographics
NPI:1851455604
Name:EBONY HOUSE INC
Entity Type:Organization
Organization Name:EBONY HOUSE INC
Other - Org Name:ELBA HOUSE
Other - Org Type:Other Name
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:
Authorized Official - First Name:CHE
Authorized Official - Middle Name:
Authorized Official - Last Name:JORDAN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:602-276-4288
Mailing Address - Street 1:6222 S 13TH ST
Mailing Address - Street 2:
Mailing Address - City:PHOENIX
Mailing Address - State:AZ
Mailing Address - Zip Code:85042-4408
Mailing Address - Country:US
Mailing Address - Phone:602-276-4288
Mailing Address - Fax:602-232-2938
Practice Address - Street 1:8646 S 14TH ST
Practice Address - Street 2:
Practice Address - City:PHOENIX
Practice Address - State:AZ
Practice Address - Zip Code:85042-7902
Practice Address - Country:US
Practice Address - Phone:602-243-5491
Practice Address - Fax:602-243-5486
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-12-19
Last Update Date:2023-07-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZBH2371324500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes324500000XResidential Treatment FacilitiesSubstance Abuse Rehabilitation Facility
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ845604OtherAHCCCS NUMBER