Healthcare Provider Details

I. General information

NPI: 1922465434
Provider Name (Legal Business Name): CHURCH OF THE OVERCOMER
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/28/2016
Last Update Date: 01/28/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1010 SUNSET ST
TRAINER PA
19061-5224
US

IV. Provider business mailing address

1010 SUNSET ST
TRAINER PA
19061-5224
US

V. Phone/Fax

Practice location:
  • Phone: 610-485-6090
  • Fax:
Mailing address:
  • Phone: 610-485-6090
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code305R00000X
TaxonomyPreferred Provider Organization
License Number
License Number StatePA
# 2
Primary TaxonomyN
Taxonomy Code305S00000X
TaxonomyPoint of Service
License Number
License Number StatePA

VIII. Authorized Official

Name: DR. CAROLYIN C. COLLINS
Title or Position: DIRECTOR
Credential: M.H.S, D.D
Phone: 610-485-6090