Provider Demographics
NPI:1124214317
Name:DOMINION MINISTRIES
Entity Type:Organization
Organization Name:DOMINION MINISTRIES
Other - Org Name:COMMUNITY SUPPORT
Other - Org Type:Other Name
Authorized Official - Title/Position:EXECUTIVE ASSISTANT
Authorized Official - Prefix:MRS
Authorized Official - First Name:CYNTHIA
Authorized Official - Middle Name:DENNIS
Authorized Official - Last Name:JOHNSON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:919-416-1830
Mailing Address - Street 1:1530 N GREGSON ST
Mailing Address - Street 2:SUITE 3D
Mailing Address - City:DURHAM
Mailing Address - State:NC
Mailing Address - Zip Code:27701-1155
Mailing Address - Country:US
Mailing Address - Phone:919-416-1830
Mailing Address - Fax:
Practice Address - Street 1:1530 N GREGSON ST
Practice Address - Street 2:SUITE 3D
Practice Address - City:DURHAM
Practice Address - State:NC
Practice Address - Zip Code:27701-1155
Practice Address - Country:US
Practice Address - Phone:919-416-1830
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-09-20
Last Update Date:2007-09-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251S00000XAgenciesCommunity/Behavioral Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC8300909BMedicaid