Provider Demographics
NPI: | 1164617072 |
---|---|
Name: | DOMINION MINISTRIES |
Entity Type: | Organization |
Organization Name: | DOMINION MINISTRIES |
Other - Org Name: | DIAGNOSTIC ASSESSMENT |
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: | 2007-09-13 |
Last Update Date: | 2007-09-13 |
Deactivation Date: | |
Deactivation Code: | |
Reactivation Date: |
Provider Taxonomies
Primary? | Code | Type | Classification | Specialization |
---|---|---|---|---|
Yes | 251S00000X | Agencies | Community/Behavioral Health |
Provider Identifiers
State | Identifier ID | ID Type | Issuer |
---|---|---|---|
NC | 8300909G | Medicaid |