Healthcare Provider Details

I. General information

NPI: 1740986314
Provider Name (Legal Business Name): CITY OF JESUS PROMISE LAND, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 02/06/2023
Last Update Date: 02/08/2023
Certification Date: 02/08/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1321 HUMPHREY ST
DURHAM NC
27701-4229
US

IV. Provider business mailing address

1321 HUMPHREY ST
DURHAM NC
27701-4229
US

V. Phone/Fax

Practice location:
  • Phone: 919-641-1337
  • Fax:
Mailing address:
  • Phone: 919-641-1337
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code343900000X
TaxonomyNon-emergency Medical Transport (VAN)
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code347C00000X
TaxonomyPrivate Vehicle
License Number
License Number State

VIII. Authorized Official

Name: ANNIE WOODY
Title or Position: OWNER
Credential:
Phone: 919-641-1337