Provider Demographics
NPI:1164043196
Name:GOLDEN GATE ADULT REHABILITATION MINISTRY
Entity Type:Organization
Organization Name:GOLDEN GATE ADULT REHABILITATION MINISTRY
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PROGRAM DIRECTOR
Authorized Official - Prefix:
Authorized Official - First Name:OBIE
Authorized Official - Middle Name:
Authorized Official - Last Name:BUSSEY
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:214-943-5010
Mailing Address - Street 1:1128 REVEREND CBT SMITH ST
Mailing Address - Street 2:
Mailing Address - City:DALLAS
Mailing Address - State:TX
Mailing Address - Zip Code:75203-1536
Mailing Address - Country:US
Mailing Address - Phone:214-943-5010
Mailing Address - Fax:
Practice Address - Street 1:1128 REVEREND CBT SMITH ST
Practice Address - Street 2:
Practice Address - City:DALLAS
Practice Address - State:TX
Practice Address - Zip Code:75203-1536
Practice Address - Country:US
Practice Address - Phone:214-943-5010
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2020-04-30
Last Update Date:2020-04-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QR0800XAmbulatory Health Care FacilitiesClinic/CenterRecovery Care