MEDICARE: CHRIST TABERNACLE MINISTRIES OF EXCELLENCE INC.

Medicare Provider Information

Scope of Practice

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

#	Taxonomy Code	Taxonomy	License Number State
1	101YM0800X	Mental Health Counselor
2	101YP1600X	Pastoral Counselor
3	163WA2000X	Administrator Registered Nurse
4	163WD0400X	Diabetes Educator Registered Nurse
5	174H00000X	Health Educator
6	261QP2300X	Primary Care Clinic/Center	OH

General Provider Information

NPI Number	:	1912314436
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	CHRIST TABERNACLE MINISTRIES OF EXCELLENCE INC.

Provider Business Mailing Address
First Line	:	11260 CHESTER RD STE 240
Second Line	:
City	:	CINCINNATI
State	:	OH
Zip	:	45246-4050
Country	:	US
Telephone Number	:	513-771-3412
Fax Number	:

Provider Business Practice Location Address
First Line	:	11260 CHESTER RD STE 240
Second Line	:
City	:	CINCINNATI
State	:	OH
Zip	:	45246-4050
Country	:	US
Telephone Number	:	513-771-3412
Fax Number	:

Authorized Official
Title or Position	:	PRACTITIONER
Name	:	DR. EDNA DENISE LACKEY
Credential	:	RN MBA PH.D
Telephone Number	:	513-771-3412

Provider Enumeration Date	:	07/16/2014
Last Update Date	:	07/16/2014

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