=====================================================
General NPI Number Information
=====================================================
NPI Number | 1053510297
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | THORMINC, THE HOUSE OF REFUGE MINISTRIES, INC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 07/17/2007
-----------------------------------------------------
Last Update Date | 07/17/2007
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 2137 N LIBERTY ST
-----------------------------------------------------
City | JACKSONVILLE
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 32206-3827
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 904-354-2233
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | PO BOX 28338
-----------------------------------------------------
City | JACKSONVILLE
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 32226-8338
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 904-354-2233
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | EXECUTIVE DIRECTOR
-----------------------------------------------------
Name | MRS. CASSANDRA LAFAYE BUSH
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 904-536-8155
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 251B00000X
-----------------------------------------------------
Taxonomy Name | Case Management Agency
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------