Provider Demographics
NPI:1982461380
Name:BLACKAGE, LLC
Entity Type:Organization
Organization Name:BLACKAGE, LLC
Other - Org Name:ONE WELL CLINIC
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:COURTENEY
Authorized Official - Middle Name:GENIECE
Authorized Official - Last Name:NELSON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:916-779-9212
Mailing Address - Street 1:112 S ALLEN ST
Mailing Address - Street 2:
Mailing Address - City:ALBANY
Mailing Address - State:NY
Mailing Address - Zip Code:12208-2205
Mailing Address - Country:US
Mailing Address - Phone:916-779-9212
Mailing Address - Fax:
Practice Address - Street 1:320 CENTRAL PARK W UNIT 18B
Practice Address - Street 2:
Practice Address - City:NEW YORK
Practice Address - State:NY
Practice Address - Zip Code:10025-7659
Practice Address - Country:US
Practice Address - Phone:916-779-9212
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2024-03-01
Last Update Date:2024-03-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes405300000XOther Service ProvidersPrevention ProfessionalGroup - Multi-Specialty
No251E00000XAgenciesHome HealthGroup - Multi-Specialty
No251S00000XAgenciesCommunity/Behavioral HealthGroup - Multi-Specialty
No253Z00000XAgenciesIn Home Supportive CareGroup - Multi-Specialty
No261QM0801XAmbulatory Health Care FacilitiesClinic/CenterMental Health (Including Community Mental Health Center)Group - Multi-Specialty
No261QP0905XAmbulatory Health Care FacilitiesClinic/CenterPublic Health, State or LocalGroup - Multi-Specialty
No374K00000XNursing Service Related ProvidersReligious Nonmedical PractitionerGroup - Multi-Specialty
No385H00000XRespite Care FacilityRespite CareGroup - Multi-Specialty
No252Y00000XAgenciesEarly Intervention Provider Agency
No261QM1300XAmbulatory Health Care FacilitiesClinic/CenterMulti-Specialty
No261QP2400XAmbulatory Health Care FacilitiesClinic/CenterPrison Health
No261QR1100XAmbulatory Health Care FacilitiesClinic/CenterResearch
No261QR1300XAmbulatory Health Care FacilitiesClinic/CenterRural Health