Provider Demographics
NPI:1205673183
Name:OTHER SIDE OF PLAY LLC
Entity type:Organization
Organization Name:OTHER SIDE OF PLAY LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:CASEY
Authorized Official - Middle Name:
Authorized Official - Last Name:TUELL
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:850-294-4666
Mailing Address - Street 1:PO BOX 5211
Mailing Address - Street 2:
Mailing Address - City:SAINT MARYS
Mailing Address - State:GA
Mailing Address - Zip Code:31558-5211
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1454 HORSESHOE COVE RD
Practice Address - Street 2:
Practice Address - City:WAVERLY
Practice Address - State:GA
Practice Address - Zip Code:31565-2110
Practice Address - Country:US
Practice Address - Phone:850-294-4666
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2024-07-09
Last Update Date:2024-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational TherapistGroup - Single Specialty