Provider Demographics
NPI:1427796523
Name:OUTSIDE THE BOX THERAPY, LLC
Entity type:Organization
Organization Name:OUTSIDE THE BOX THERAPY, LLC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:MEMBER
Authorized Official - Prefix:
Authorized Official - First Name:JARED
Authorized Official - Middle Name:
Authorized Official - Last Name:CORDUM
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:217-415-0855
Mailing Address - Street 1:PO BOX 5751
Mailing Address - Street 2:
Mailing Address - City:CLOVIS
Mailing Address - State:NM
Mailing Address - Zip Code:88102-5751
Mailing Address - Country:US
Mailing Address - Phone:217-415-0855
Mailing Address - Fax:
Practice Address - Street 1:3009 N PRINCE ST # 46
Practice Address - Street 2:
Practice Address - City:CLOVIS
Practice Address - State:NM
Practice Address - Zip Code:88101-3818
Practice Address - Country:US
Practice Address - Phone:217-415-0855
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2022-05-26
Last Update Date:2022-06-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225XP0200XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational TherapistPediatricsGroup - Single Specialty