Healthcare Provider Details

I. General information

NPI: 1225368640
Provider Name (Legal Business Name): OUR SPACE CLUBHOUSE
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/07/2010
Last Update Date: 01/07/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

644 BLAKELY ST
CUTHBERT GA
39840-5325
US

IV. Provider business mailing address

2100 COMER AVE
COLUMBUS GA
31904-8725
US

V. Phone/Fax

Practice location:
  • Phone: 229-732-5050
  • Fax: 229-732-5058
Mailing address:
  • Phone: 706-596-5583
  • Fax: 706-596-5589

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number
License Number State

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

VIII. Authorized Official

Name: PERRY ALEXANDER
Title or Position: CEO
Credential:
Phone: 706-596-5757