MEDICARE: GOLDEN GATE ADULT REHABILITATION MINISTRY

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	261QR0800X	Recovery Care Clinic/Center

General Provider Information

NPI Number	:	1164043196
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	GOLDEN GATE ADULT REHABILITATION MINISTRY

Provider Business Mailing Address
First Line	:	1128 REVEREND CBT SMITH ST
Second Line	:
City	:	DALLAS
State	:	TX
Zip	:	75203-1536
Country	:	US
Telephone Number	:	214-943-5010
Fax Number	:

Provider Business Practice Location Address
First Line	:	1128 REVEREND CBT SMITH ST
Second Line	:
City	:	DALLAS
State	:	TX
Zip	:	75203-1536
Country	:	US
Telephone Number	:	214-943-5010
Fax Number	:

Authorized Official
Title or Position	:	PROGRAM DIRECTOR
Name	:	OBIE BUSSEY
Credential	:
Telephone Number	:	214-943-5010

Provider Enumeration Date	:	04/30/2020
Last Update Date	:	04/30/2020

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