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General NPI Number Information
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NPI Number | 1275674186
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Entity Type | Organization
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Legal Business Name | SIDE BY SIDE CLUBHOUSE, INC.
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Dates
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Enumeration Date | 02/12/2007
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Last Update Date | 05/05/2010
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Provider Practice Location Address
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Address Line | 1001 MAIN ST
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City | STONE MOUNTAIN
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State | GA
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Zip | 30083-2922
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Country | US
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Telephone | 404-378-1139
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Fax | 404-378-1164
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Provider Business Mailing Address
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Address Line | 1001 MAIN ST
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City | STONE MOUNTAIN
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State | GA
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Zip | 30083-2922
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Country | US
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Telephone | 770-469-9355
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Fax | 770-469-9385
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Authorized Official
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Title or Position | EXECUTIVE DIRECTOR
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Name | MS. CYNTHIA JOHNSON
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Credential | MA
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Telephone | 770-469-9355
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 251S00000X
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Taxonomy Name | Community/Behavioral Health Agency
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License Number |
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License Number State |
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