Provider Demographics
NPI:1235439159
Name:LIVING WATERS PRISONER MINISTERIES
Entity Type:Organization
Organization Name:LIVING WATERS PRISONER MINISTERIES
Other - Org Name:LIVING WATERS OUTREACH PROGRAM
Other - Org Type:Former Legal Business Name
Authorized Official - Title/Position:CASE MANAGER
Authorized Official - Prefix:MR
Authorized Official - First Name:TERRY
Authorized Official - Middle Name:CHRISTOPHER
Authorized Official - Last Name:SPEAKS
Authorized Official - Suffix:
Authorized Official - Credentials:CHRISTIAN COUNSILOR
Authorized Official - Phone:336-710-2019
Mailing Address - Street 1:355 GALLOWAY ST
Mailing Address - Street 2:
Mailing Address - City:MOUNT AIRY
Mailing Address - State:NC
Mailing Address - Zip Code:27030-3711
Mailing Address - Country:US
Mailing Address - Phone:336-719-2019
Mailing Address - Fax:
Practice Address - Street 1:355 GALLOWAY ST
Practice Address - Street 2:
Practice Address - City:MOUNT AIRY
Practice Address - State:NC
Practice Address - Zip Code:27030
Practice Address - Country:US
Practice Address - Phone:336-719-2019
Practice Address - Fax:336-719-2019
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:LIVING WATERS PRISONER MINISTRIES
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2010-10-26
Last Update Date:2010-10-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
302F00000X
NC324500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes324500000XResidential Treatment FacilitiesSubstance Abuse Rehabilitation Facility
No302F00000XManaged Care OrganizationsExclusive Provider Organization