Healthcare Provider Details

I. General information

NPI: 1972733053
Provider Name (Legal Business Name): REACHING OUT MINISTRIES
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/22/2009
Last Update Date: 07/22/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

226 CHALAN SAN ANTONIO STE C AMPARO'S BUSINESS CENTER
TAMUNING GU
96913-3525
US

IV. Provider business mailing address

226 CHALAN SAN ANTONIO STE C AMPARO'S BUSINESS CENTER
TAMUNING GU
96913-3525
US

V. Phone/Fax

Practice location:
  • Phone: 671-646-2010
  • Fax: 671-646-2070
Mailing address:
  • Phone: 671-646-2010
  • Fax: 671-646-2070

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code261QD0000X
TaxonomyDental Clinic/Center
License Number14605
License Number StateTX
# 2
Primary TaxonomyY
Taxonomy Code261QD0000X
TaxonomyDental Clinic/Center
License NumberD927
License Number StateGU

VIII. Authorized Official

Name: DR. KENNY WAYNE BOURGEOIS
Title or Position: PRESIDENT/PRIMARY DENTAL PROVIDER
Credential: DDS
Phone: 671-646-2010