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NPI Code Detail

MEDICARE: FORT WAYNE CLUBHOUSE, INC

MEDICARE: FORT WAYNE CLUBHOUSE, INC
Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

# Taxonomy Code Taxonomy License Number License Number State
1251S00000XCommunity/Behavioral Health Agency

General Provider Information

NPI Number : 1346601366
Entity Type Code : Organization
Provider Name (Legal Business Name) : FORT WAYNE CLUBHOUSE, INC
Provider Business Mailing Address
First Line : 3327 LAKE AVE
Second Line :
City : FORT WAYNE
State : IN
Zip : 46805-5529
Country : US
Telephone Number : 260-414-8164
Fax Number : 260-423-4621
Provider Business Practice Location Address
First Line : 3327 LAKE AVE
Second Line :
City : FORT WAYNE
State : IN
Zip : 46805-5529
Country : US
Telephone Number : 260-414-8164
Fax Number : 260-423-4621
Authorized Official
Title or Position : EXECUTIVE DIRECTOR
Name : MR. ALEXANDER CHARLES WILSON
Credential : MTS
Telephone Number : 260-414-8164
Provider Enumeration Date : 03/18/2016
Last Update Date : 03/18/2016

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Directions to “FORT WAYNE CLUBHOUSE, INC ” Practice Location

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