MEDICARE: AWAY OUT, 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
1	251B00000X	Case Management Agency	LPC2759	GA
2	251S00000X	Community/Behavioral Health Agency	LPC2759	GA

General Provider Information

NPI Number	:	1831419639
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	AWAY OUT, INC.

Provider Business Mailing Address
First Line	:	416 12TH STREET SUITE 202
Second Line	:
City	:	COLUMBUS
State	:	GA
Zip	:	31901
Country	:	US
Telephone Number	:	706-653-0068
Fax Number	:

Provider Business Practice Location Address
First Line	:	416 12TH ST STE 202
Second Line	:
City	:	COLUMBUS
State	:	GA
Zip	:	31901-2558
Country	:	US
Telephone Number	:	706-653-0068
Fax Number	:

Authorized Official
Title or Position	:	CEO
Name	:	MR. EDDIE D POWELL
Credential	:	LPC
Telephone Number	:	706-653-0068

Provider Enumeration Date	:	06/03/2010
Last Update Date	:	06/03/2010

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Directions to “AWAY OUT, INC. ” Practice Location

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