Healthcare Provider Details

I. General information

NPI: 1912314436
Provider Name (Legal Business Name): CHRIST TABERNACLE MINISTRIES OF EXCELLENCE INC.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/16/2014
Last Update Date: 07/16/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

11260 CHESTER RD STE 240
CINCINNATI OH
45246-4050
US

IV. Provider business mailing address

11260 CHESTER RD STE 240
CINCINNATI OH
45246-4050
US

V. Phone/Fax

Practice location:
  • Phone: 513-771-3412
  • Fax:
Mailing address:
  • Phone: 513-771-3412
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QP2300X
TaxonomyPrimary Care Clinic/Center
License Number
License Number StateOH
# 2
Primary TaxonomyN
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number
License Number StateNULL
# 3
Primary TaxonomyN
Taxonomy Code101YP1600X
TaxonomyPastoral Counselor
License Number
License Number StateNULL
# 4
Primary TaxonomyN
Taxonomy Code163WA2000X
TaxonomyAdministrator Registered Nurse
License Number
License Number StateNULL
# 5
Primary TaxonomyN
Taxonomy Code163WD0400X
TaxonomyDiabetes Educator Registered Nurse
License Number
License Number StateNULL
# 6
Primary TaxonomyN
Taxonomy Code174H00000X
TaxonomyHealth Educator
License Number
License Number StateNULL

VIII. Authorized Official

Name: DR. EDNA DENISE LACKEY
Title or Position: PRACTITIONER
Credential: RN MBA PH.D
Phone: 513-771-3412