=====================================================
General NPI Number Information
=====================================================
NPI Number | 1114262235
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | LIFE QUEST MINISTRY INC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 11/29/2012
-----------------------------------------------------
Last Update Date | 11/29/2012
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 12505 GRANDVIEW RD
-----------------------------------------------------
City | GRANDVIEW
-----------------------------------------------------
State | MO
-----------------------------------------------------
Zip | 64030-1703
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 816-765-8211
-----------------------------------------------------
Fax | 816-765-8215
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 12505 GRANDVIEW RD
-----------------------------------------------------
City | GRANDVIEW
-----------------------------------------------------
State | MO
-----------------------------------------------------
Zip | 64030-1703
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 816-765-8211
-----------------------------------------------------
Fax | 816-765-8215
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | VICE-PRESIDENT
-----------------------------------------------------
Name | MR. KEITH A WHITE
-----------------------------------------------------
Credential | MA LPC
-----------------------------------------------------
Telephone | 816-765-8211
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 101YP2500X
-----------------------------------------------------
Taxonomy Name | Professional Counselor
-----------------------------------------------------
License Number | 2001013216
-----------------------------------------------------
License Number State | MO
-----------------------------------------------------