Healthcare Provider Details

I. General information

NPI: 1073796447
Provider Name (Legal Business Name): EAST GATE CONNECTIONS
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/08/2007
Last Update Date: 12/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4297 VERNON RD APT B
HARRINGTON DE
19952-4215
US

IV. Provider business mailing address

4297 VERNON RD APT B
HARRINGTON DE
19952-4215
US

V. Phone/Fax

Practice location:
  • Phone: 302-632-5338
  • Fax:
Mailing address:
  • Phone: 302-632-5338
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YP1600X
TaxonomyPastoral Counselor
License Number
License Number State

VIII. Authorized Official

Name: MR. DYNEZ ORTEGA BOLDEN
Title or Position: CEO & PRESIDENT
Credential: C.C.C.
Phone: 302-632-5338