Provider Demographics
NPI:1275938763
Name:ABILITY CLUB CORPORATION
Entity Type:Organization
Organization Name:ABILITY CLUB CORPORATION
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:MR
Authorized Official - First Name:WADE
Authorized Official - Middle Name:MITCHELL
Authorized Official - Last Name:OGLETREE
Authorized Official - Suffix:
Authorized Official - Credentials:MS
Authorized Official - Phone:251-404-0016
Mailing Address - Street 1:11551 PINE DR
Mailing Address - Street 2:
Mailing Address - City:GULFPORT
Mailing Address - State:MS
Mailing Address - Zip Code:39503-3998
Mailing Address - Country:US
Mailing Address - Phone:251-404-0016
Mailing Address - Fax:
Practice Address - Street 1:11551 PINE DR
Practice Address - Street 2:
Practice Address - City:GULFPORT
Practice Address - State:MS
Practice Address - Zip Code:39503-3998
Practice Address - Country:US
Practice Address - Phone:251-404-0016
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-10-27
Last Update Date:2014-10-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251S00000XAgenciesCommunity/Behavioral Health