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General NPI Number Information
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NPI Number | 1912712381
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Entity Type | Organization
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Legal Business Name | MOURNING GLORY CLUB INC
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Dates
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Enumeration Date | 02/11/2025
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Last Update Date | 02/11/2025
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Provider Practice Location Address
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Address Line | 7 FLEET ST APT 108
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City | MARINA DEL REY
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State | CA
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Zip | 90292-5731
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Country | US
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Telephone | 646-436-5976
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Fax |
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Provider Business Mailing Address
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Address Line | 7 FLEET ST APT 108
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City | MARINA DEL REY
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State | CA
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Zip | 90292-5731
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Country | US
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Telephone | 646-436-5976
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Fax |
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Authorized Official
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Title or Position | FOUNDER
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Name | ALEKSEI ARCHER
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Credential |
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Telephone | 646-436-5976
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 225XM0800X
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Taxonomy Name | Mental Health Occupational Therapist
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License Number |
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License Number State |
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