Provider Demographics
NPI:1679392559
Name:REPAIRER OF THE BREACH MINISTRIES INCORPORATED
Entity type:Organization
Organization Name:REPAIRER OF THE BREACH MINISTRIES INCORPORATED
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:FOUNDER/CEO/CAO/CFO
Authorized Official - Prefix:DR
Authorized Official - First Name:MILDRED
Authorized Official - Middle Name:
Authorized Official - Last Name:EWING
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:219-334-6393
Mailing Address - Street 1:3220 W RIDGE RD
Mailing Address - Street 2:
Mailing Address - City:GARY
Mailing Address - State:IN
Mailing Address - Zip Code:46408-1834
Mailing Address - Country:US
Mailing Address - Phone:219-334-6393
Mailing Address - Fax:
Practice Address - Street 1:3220 W RIDGE RD
Practice Address - Street 2:
Practice Address - City:GARY
Practice Address - State:IN
Practice Address - Zip Code:46408-1834
Practice Address - Country:US
Practice Address - Phone:219-334-6393
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2024-10-07
Last Update Date:2025-01-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251S00000XAgenciesCommunity/Behavioral Health
No251B00000XAgenciesCase Management