Fort Wayne Clubhouse, Inc

Primary specialty

Community/Behavioral Health AgencyTaxonomy code 251S00000X

Legal business name

FORT WAYNE CLUBHOUSE, INC

Practice address

3327 Lake Ave
Fort Wayne, IN 46805-5529

Phone

(260) 414-8164

Fax

(260) 423-4621

NPI assigned

Mar 18, 2016

Organization subpart

No

Registry information is reported by the provider to CMS and is not verified. About this source

Authorized official

Name

Mr. Alexander Charles Wilson, MTS

Title

Executive Director

Phone

(260) 414-8164

Specialties & licenses 1

Addresses

Other names 1

• The Carriage House Doing business as

Locations

The complete NPPES record for this NPI in the NPI Registry API format.

{
    "created_epoch": "1458259200000",
    "enumeration_type": "NPI-2",
    "last_updated_epoch": "1458259200000",
    "number": "1346601366",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "3327 LAKE AVE",
            "city": "FORT WAYNE",
            "state": "IN",
            "postal_code": "468055529",
            "telephone_number": "260-414-8164",
            "fax_number": "260-423-4621"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "3327 LAKE AVE",
            "city": "FORT WAYNE",
            "state": "IN",
            "postal_code": "468055529",
            "telephone_number": "260-414-8164",
            "fax_number": "260-423-4621"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "organization_name": "FORT WAYNE CLUBHOUSE, INC",
        "organizational_subpart": "NO",
        "enumeration_date": "2016-03-18",
        "last_updated": "2016-03-18",
        "status": "A",
        "authorized_official_last_name": "WILSON",
        "authorized_official_first_name": "ALEXANDER",
        "authorized_official_middle_name": "CHARLES",
        "authorized_official_title_or_position": "EXECUTIVE DIRECTOR",
        "authorized_official_telephone_number": "260-414-8164",
        "authorized_official_name_prefix": "Mr.",
        "authorized_official_credential": "MTS"
    },
    "taxonomies": [
        {
            "code": "251S00000X",
            "taxonomy_group": "",
            "desc": "Community/Behavioral Health",
            "state": null,
            "license": null,
            "primary": true
        }
    ],
    "identifiers": [],
    "endpoints": [],
    "other_names": [
        {
            "organization_name": "The Carriage House",
            "code": "3",
            "type": "Doing Business As"
        }
    ]
}

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• Community/Behavioral Health Agency in Fort Wayne, IN
• Providers in Fort Wayne, IN by specialty
• Community/Behavioral Health Agency in Indiana

• NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Last updated by the provider on Mar 18, 2016; self-reported and not verified by CMS. Specialty names from the NUCC taxonomy.
• National Provider Directory (CMS): practice roles, locations, licenses, networks and endpoints.

Verify at the official NPI Registry.