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General NPI Number Information
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NPI Number | 1376964783
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Entity Type | Organization
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Legal Business Name | COMINGOUT CHRISTIAN OUTREACH ORG.
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Dates
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Enumeration Date | 01/02/2014
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Last Update Date | 01/02/2014
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Provider Practice Location Address
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Address Line | 1021 NICKLAUS DR
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City | SUFFOLK
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State | VA
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Zip | 23435-4102
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Country | US
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Telephone | 757-508-6671
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Fax | 757-934-9294
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Provider Business Mailing Address
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Address Line | 1021 NICKLAUS DR
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City | SUFFOLK
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State | VA
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Zip | 23435-4102
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Country | US
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Telephone | 757-508-6671
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Fax | 757-934-9294
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Authorized Official
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Title or Position | OWNER
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Name | MS. MURIEL CONCETTA WALLACECER
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Credential | CERT.
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Telephone | 757-508-6671
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 251S00000X
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Taxonomy Name | Community/Behavioral Health Agency
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License Number | S4070266
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License Number State | VA
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