Provider Demographics
NPI:1679714810
Name:PRAISE THE LORD MINISTRY
Entity type:Organization
Organization Name:PRAISE THE LORD MINISTRY
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:OFFICER MANAGER
Authorized Official - Prefix:MR
Authorized Official - First Name:TYRONE
Authorized Official - Middle Name:
Authorized Official - Last Name:JOHNSON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:941-425-3640
Mailing Address - Street 1:338 RHEW ST
Mailing Address - Street 2:
Mailing Address - City:FAYETTEVILLE
Mailing Address - State:NC
Mailing Address - Zip Code:28303-3354
Mailing Address - Country:US
Mailing Address - Phone:910-425-3640
Mailing Address - Fax:910-425-0150
Practice Address - Street 1:338 RHEW ST
Practice Address - Street 2:
Practice Address - City:FAYETTEVILLE
Practice Address - State:NC
Practice Address - Zip Code:28303-3354
Practice Address - Country:US
Practice Address - Phone:910-425-3640
Practice Address - Fax:910-425-0150
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-03-18
Last Update Date:2009-03-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NCHC2573253Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes253Z00000XAgenciesIn Home Supportive Care
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC3409609Medicaid