Healthcare Provider Details

I. General information

NPI: 1912712381
Provider Name (Legal Business Name): MOURNING GLORY CLUB INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 02/11/2025
Last Update Date: 02/11/2025
Certification Date: 02/11/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

7 FLEET ST APT 108
MARINA DEL REY CA
90292-5731
US

IV. Provider business mailing address

7 FLEET ST APT 108
MARINA DEL REY CA
90292-5731
US

V. Phone/Fax

Practice location:
  • Phone: 646-436-5976
  • Fax:
Mailing address:
  • Phone: 646-436-5976
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225XM0800X
TaxonomyMental Health Occupational Therapist
License Number
License Number State

VIII. Authorized Official

Name: ALEKSEI ARCHER
Title or Position: FOUNDER
Credential:
Phone: 646-436-5976