Provider Demographics
NPI:1053655035
Name:THEOPHILOS III (IDO) INTERGENERATIONAL DIVERSIFIED OUTREACH MINISTRIES
Entity Type:Organization
Organization Name:THEOPHILOS III (IDO) INTERGENERATIONAL DIVERSIFIED OUTREACH MINISTRIES
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT CEO COMMUNITY OUTREACH
Authorized Official - Prefix:MRS
Authorized Official - First Name:DIANE
Authorized Official - Middle Name:
Authorized Official - Last Name:COGSDELL
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:240-678-0143
Mailing Address - Street 1:206 N HAYNE ST STE A
Mailing Address - Street 2:
Mailing Address - City:MONROE
Mailing Address - State:NC
Mailing Address - Zip Code:28112-4866
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:206 N HAYNE ST STE A
Practice Address - Street 2:
Practice Address - City:MONROE
Practice Address - State:NC
Practice Address - Zip Code:28112-4866
Practice Address - Country:US
Practice Address - Phone:704-635-8860
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-11-15
Last Update Date:2012-11-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251E00000XAgenciesHome Health