Healthcare Provider Details

I. General information

NPI: 1598058232
Provider Name (Legal Business Name): OVER THE EDGE GROUP HOME FOR DISABLE
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/26/2011
Last Update Date: 05/26/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

7010 PHOENIX AVE NE APT 310
ALBUQUERQUE NM
87110-3505
US

IV. Provider business mailing address

7010 PHOENIX AVE NE APT 310
ALBUQUERQUE NM
87110-3505
US

V. Phone/Fax

Practice location:
  • Phone: 505-508-5708
  • Fax:
Mailing address:
  • Phone: 505-508-5708
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261Q00000X
TaxonomyClinic/Center
License Number
License Number State

VIII. Authorized Official

Name: MR. AUTRELL SHERROD BROWN
Title or Position: OWNER/CEO
Credential:
Phone: 505-463-6328