Provider Demographics
NPI:1598058232
Name:OVER THE EDGE GROUP HOME FOR DISABLE
Entity type:Organization
Organization Name:OVER THE EDGE GROUP HOME FOR DISABLE
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:OWNER/CEO
Authorized Official - Prefix:MR
Authorized Official - First Name:AUTRELL
Authorized Official - Middle Name:SHERROD
Authorized Official - Last Name:BROWN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:505-463-6328
Mailing Address - Street 1:7010 PHOENIX AVE NE APT 310
Mailing Address - Street 2:
Mailing Address - City:ALBUQUERQUE
Mailing Address - State:NM
Mailing Address - Zip Code:87110-3505
Mailing Address - Country:US
Mailing Address - Phone:505-508-5708
Mailing Address - Fax:
Practice Address - Street 1:7010 PHOENIX AVE NE APT 310
Practice Address - Street 2:
Practice Address - City:ALBUQUERQUE
Practice Address - State:NM
Practice Address - Zip Code:87110-3505
Practice Address - Country:US
Practice Address - Phone:505-508-5708
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-05-26
Last Update Date:2011-05-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261Q00000XAmbulatory Health Care FacilitiesClinic/Center