Healthcare Provider Details

I. General information

NPI: 1497958177
Provider Name (Legal Business Name): OVERCOMERS OUTREACH MINISTRIES
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/08/2007
Last Update Date: 08/22/2020
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2020 BLOOMINGTON AVE
MINNEAPOLIS MN
55404-3073
US

IV. Provider business mailing address

2020 BLOOMINGTON AVE
MINNEAPOLIS MN
55404-3073
US

V. Phone/Fax

Practice location:
  • Phone: 612-871-1208
  • Fax: 612-871-1219
Mailing address:
  • Phone: 612-871-1208
  • Fax: 612-871-1219

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code302R00000X
TaxonomyHealth Maintenance Organization
License Number1010090
License Number StateMN

VIII. Authorized Official

Name: MRS. SHEILA ANN THAYER
Title or Position: PROGRAM DIRECTOR
Credential:
Phone: 612-871-1208