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General NPI Number Information
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NPI Number | 1275401796
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Entity Type | Organization
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Legal Business Name | FRIENDS OF CLUB 21
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Dates
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Enumeration Date | 10/27/2025
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Last Update Date | 10/27/2025
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Provider Practice Location Address
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Address Line | 301 AUSTIN BLUFFS PKWY
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City | COLORADO SPRINGS
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State | CO
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Zip | 80918-3922
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Country | US
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Telephone | 360-789-4935
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Fax |
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Provider Business Mailing Address
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Address Line | 3472 RESEARCH PKWY STE 104-405
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City | COLORADO SPRINGS
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State | CO
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Zip | 80920-1066
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Country | US
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Telephone | 360-789-4935
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Fax |
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Authorized Official
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Title or Position | CHIEF OPERATING OFFICER
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Name | JOSEPH MASON
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Credential |
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Telephone | 360-789-4935
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 373H00000X
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Taxonomy Name | Day Training/Habilitation Specialist
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License Number |
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License Number State |
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