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General NPI Number Information
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NPI Number | 1598058232
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Entity Type | Organization
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Legal Business Name | OVER THE EDGE GROUP HOME FOR DISABLE
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Dates
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Enumeration Date | 05/26/2011
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Last Update Date | 05/26/2011
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Provider Practice Location Address
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Address Line | 7010 PHOENIX AVE NE APT 310
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City | ALBUQUERQUE
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State | NM
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Zip | 87110-3505
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Country | US
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Telephone | 505-508-5708
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Fax |
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Provider Business Mailing Address
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Address Line | 7010 PHOENIX AVE NE APT 310
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City | ALBUQUERQUE
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State | NM
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Zip | 87110-3505
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Country | US
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Telephone | 505-508-5708
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Fax |
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Authorized Official
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Title or Position | OWNER/CEO
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Name | MR. AUTRELL SHERROD BROWN
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Credential |
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Telephone | 505-463-6328
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 261Q00000X
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Taxonomy Name | Clinic/Center
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License Number |
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License Number State |
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