Healthcare Provider Details

I. General information

NPI: 1487043410
Provider Name (Legal Business Name): SUNDANCE RANCH CHRISTIAN CHURCH
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/14/2015
Last Update Date: 01/14/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

390 S COURTENAY PKWY
MERRITT ISLAND FL
32952-4847
US

IV. Provider business mailing address

1900 PINE ISLAND RD
MERRITT ISLAND FL
32953-6517
US

V. Phone/Fax

Practice location:
  • Phone: 321-305-5946
  • Fax:
Mailing address:
  • Phone: 215-559-1184
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YP1600X
TaxonomyPastoral Counselor
License Number204811419
License Number StateFL

VIII. Authorized Official

Name: TERRY LYNN WHARTON
Title or Position: EXECUTIVE DIRECTOR
Credential: PHD
Phone: 321-305-5946