Provider Demographics
NPI:1912343302
Name:OUR SPOT
Entity type:Organization
Organization Name:OUR SPOT
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:OWNER/DIRECTOR
Authorized Official - Prefix:MR
Authorized Official - First Name:ROOSEVELT
Authorized Official - Middle Name:
Authorized Official - Last Name:CONE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:912-541-2809
Mailing Address - Street 1:1015 E INMAN ST
Mailing Address - Street 2:
Mailing Address - City:STATESBORO
Mailing Address - State:GA
Mailing Address - Zip Code:30458-2049
Mailing Address - Country:US
Mailing Address - Phone:912-541-2809
Mailing Address - Fax:
Practice Address - Street 1:1015 E INMAN ST
Practice Address - Street 2:
Practice Address - City:STATESBORO
Practice Address - State:GA
Practice Address - Zip Code:30458-2049
Practice Address - Country:US
Practice Address - Phone:912-541-2809
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2013-05-13
Last Update Date:2015-01-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA13BL0437322D00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes322D00000XResidential Treatment FacilitiesResidential Treatment Facility, Emotionally Disturbed Children