Provider Demographics
NPI:1225368640
Name:OUR SPACE CLUBHOUSE
Entity Type:Organization
Organization Name:OUR SPACE CLUBHOUSE
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:
Authorized Official - First Name:PERRY
Authorized Official - Middle Name:
Authorized Official - Last Name:ALEXANDER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:706-596-5757
Mailing Address - Street 1:2100 COMER AVE
Mailing Address - Street 2:
Mailing Address - City:COLUMBUS
Mailing Address - State:GA
Mailing Address - Zip Code:31904-8725
Mailing Address - Country:US
Mailing Address - Phone:706-596-5583
Mailing Address - Fax:706-596-5589
Practice Address - Street 1:644 BLAKELY ST
Practice Address - Street 2:
Practice Address - City:CUTHBERT
Practice Address - State:GA
Practice Address - Zip Code:39840-5325
Practice Address - Country:US
Practice Address - Phone:229-732-5050
Practice Address - Fax:229-732-5058
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:NEW HORIZONS COMMUNITY SERVICE BOARD
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2010-01-07
Last Update Date:2010-01-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinicalGroup - Single Specialty