Healthcare Provider Details

I. General information

NPI: 1124352281
Provider Name (Legal Business Name): CHURCH OF THE LIVING GOD PGT
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/22/2009
Last Update Date: 09/22/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2610 E LEDBETTER DR 2610 E LEDBETTER DRIVE
DALLAS TX
75216-7404
US

IV. Provider business mailing address

2610 E LEDBETTER DR P O BOX 41485
DALLAS TX
75216-7404
US

V. Phone/Fax

Practice location:
  • Phone: 214-372-3369
  • Fax:
Mailing address:
  • Phone: 214-372-3369
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code251C00000X
TaxonomyDevelopmentally Disabled Services Day Training Agency
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code343900000X
TaxonomyNon-emergency Medical Transport (VAN)
License Number
License Number State

VIII. Authorized Official

Name: MR. CHARLES CLEVELAND JUNIOR
Title or Position: PASTOR
Credential: MINISTER
Phone: 214-372-3369