=====================================================
General NPI Number Information
=====================================================
NPI Number | 1407572092
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | LOVE MINISTRIES INTERNATIONAL CHURCH OF GOD
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 10/14/2022
-----------------------------------------------------
Last Update Date | 10/14/2022
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 3600 S STATE ROAD 7 STE 223
-----------------------------------------------------
City | MIRAMAR
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 33023-7206
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 507-262-4566
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 10700 TOWN CITY CENTER BLVD
-----------------------------------------------------
City | PEMBROKE PINES
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 33025
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone |
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER
-----------------------------------------------------
Name | ANTHONY JERRIDO
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 507-262-4566
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 101YM0800X
-----------------------------------------------------
Taxonomy Name | Mental Health Counselor
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------