MEDICARE: CHURCH OF THE LIVING GOD PGT

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	251C00000X	Developmentally Disabled Services Day Training Agency
2	343900000X	Non-emergency Medical Transport (VAN)

General Provider Information

NPI Number	:	1124352281
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	CHURCH OF THE LIVING GOD PGT

Provider Business Mailing Address
First Line	:	2610 E LEDBETTER DR
Second Line	:	P O BOX 41485
City	:	DALLAS
State	:	TX
Zip	:	75216-7404
Country	:	US
Telephone Number	:	214-372-3369
Fax Number	:

Provider Business Practice Location Address
First Line	:	2610 E LEDBETTER DR
Second Line	:	2610 E LEDBETTER DRIVE
City	:	DALLAS
State	:	TX
Zip	:	75216-7404
Country	:	US
Telephone Number	:	214-372-3369
Fax Number	:

Authorized Official
Title or Position	:	PASTOR
Name	:	MR. CHARLES CLEVELAND JUNIOR
Credential	:	MINISTER
Telephone Number	:	214-372-3369

Provider Enumeration Date	:	09/22/2009
Last Update Date	:	09/22/2009

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