Provider Demographics
NPI:1275674186
Name:SIDE BY SIDE CLUBHOUSE, INC.
Entity Type:Organization
Organization Name:SIDE BY SIDE CLUBHOUSE, INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:EXECUTIVE DIRECTOR
Authorized Official - Prefix:MS
Authorized Official - First Name:CYNTHIA
Authorized Official - Middle Name:
Authorized Official - Last Name:JOHNSON
Authorized Official - Suffix:
Authorized Official - Credentials:MA
Authorized Official - Phone:770-469-9355
Mailing Address - Street 1:1001 MAIN ST
Mailing Address - Street 2:
Mailing Address - City:STONE MOUNTAIN
Mailing Address - State:GA
Mailing Address - Zip Code:30083-2922
Mailing Address - Country:US
Mailing Address - Phone:770-469-9355
Mailing Address - Fax:770-469-9385
Practice Address - Street 1:1001 MAIN ST
Practice Address - Street 2:
Practice Address - City:STONE MOUNTAIN
Practice Address - State:GA
Practice Address - Zip Code:30083-2922
Practice Address - Country:US
Practice Address - Phone:404-378-1139
Practice Address - Fax:404-378-1164
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-02-12
Last Update Date:2010-05-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251S00000XAgenciesCommunity/Behavioral Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA000877676AMedicaid