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General NPI Number Information
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NPI Number | 1326860834
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Entity Type | Organization
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Legal Business Name | OUT THA BOX FOUNDATION
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Dates
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Enumeration Date | 10/26/2024
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Last Update Date | 10/26/2024
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Provider Practice Location Address
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Address Line | 3156 MOUNT ZION RD APT 305
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City | STOCKBRIDGE
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State | GA
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Zip | 30281-4179
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Country | US
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Telephone | 443-722-9488
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Fax |
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Provider Business Mailing Address
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Address Line | 3156 MOUNT ZION RD APT 305
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City | STOCKBRIDGE
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State | GA
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Zip | 30281-4179
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Country | US
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Telephone | 443-722-9488
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Fax |
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Authorized Official
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Title or Position | IMPARTATION STRATEGIST
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Name | RENEE BERNADETTE AMBUSH
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Credential | LM, IMS
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Telephone | 443-722-9488
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 101Y00000X
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Taxonomy Name | Counselor
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License Number |
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License Number State |
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