Healthcare Provider Details

I. General information

NPI: 1518405083
Provider Name (Legal Business Name): CHRISTIAN COMMUNITY DELIVERANCE CHURCH
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 02/05/2017
Last Update Date: 02/05/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

13421 CEDAR AVE
APPLE VALLEY MN
55124-8530
US

IV. Provider business mailing address

13421 CEDAR AVE
APPLE VALLEY MN
55124-8530
US

V. Phone/Fax

Practice location:
  • Phone: 612-275-5132
  • Fax:
Mailing address:
  • Phone: 612-275-5132
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code251E00000X
TaxonomyHome Health Agency
License Number4315
License Number StateMN

VIII. Authorized Official

Name: MILLICENT SAWYERR
Title or Position: PRSIDENT
Credential:
Phone: 612-275-5132