Healthcare Provider Details

I. General information

NPI: 1952118051
Provider Name (Legal Business Name): MNODERN ECCLESIA
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/12/2024
Last Update Date: 12/12/2024
Certification Date: 12/12/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

597 SAN PABLO DR
STONE MOUNTAIN GA
30083-3855
US

IV. Provider business mailing address

PO BOX 262
CARUTHERSVILLE MO
63830-0262
US

V. Phone/Fax

Practice location:
  • Phone: 573-479-0490
  • Fax:
Mailing address:
  • Phone: 573-497-0490
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101Y00000X
TaxonomyCounselor
License Number
License Number State

VIII. Authorized Official

Name: MR. WILLIE J SINGLETON
Title or Position: DIRECTOR
Credential:
Phone: 573-447-9049