Provider Demographics
NPI:1346601366
Name:FORT WAYNE CLUBHOUSE, INC
Entity Type:Organization
Organization Name:FORT WAYNE CLUBHOUSE, INC
Other - Org Name:THE CARRIAGE HOUSE
Other - Org Type:Doing Business As
Authorized Official - Title/Position:EXECUTIVE DIRECTOR
Authorized Official - Prefix:MR
Authorized Official - First Name:ALEXANDER
Authorized Official - Middle Name:CHARLES
Authorized Official - Last Name:WILSON
Authorized Official - Suffix:
Authorized Official - Credentials:MTS
Authorized Official - Phone:260-414-8164
Mailing Address - Street 1:3327 LAKE AVE
Mailing Address - Street 2:
Mailing Address - City:FORT WAYNE
Mailing Address - State:IN
Mailing Address - Zip Code:46805-5529
Mailing Address - Country:US
Mailing Address - Phone:260-414-8164
Mailing Address - Fax:260-423-4621
Practice Address - Street 1:3327 LAKE AVE
Practice Address - Street 2:
Practice Address - City:FORT WAYNE
Practice Address - State:IN
Practice Address - Zip Code:46805-5529
Practice Address - Country:US
Practice Address - Phone:260-414-8164
Practice Address - Fax:260-423-4621
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-03-18
Last Update Date:2016-03-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251S00000XAgenciesCommunity/Behavioral Health