Provider Demographics
NPI:1326004482
Name:SHEPHERDS GATE LIFE CHANGING CENTER
Entity Type:Organization
Organization Name:SHEPHERDS GATE LIFE CHANGING CENTER
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO/PA
Authorized Official - Prefix:MRS
Authorized Official - First Name:CHERIE
Authorized Official - Middle Name:
Authorized Official - Last Name:BENNETT
Authorized Official - Suffix:
Authorized Official - Credentials:PA
Authorized Official - Phone:972-522-5665
Mailing Address - Street 1:325 KINGFISHER LN
Mailing Address - Street 2:
Mailing Address - City:ARLINGTON
Mailing Address - State:TX
Mailing Address - Zip Code:76002-3391
Mailing Address - Country:US
Mailing Address - Phone:817-465-6522
Mailing Address - Fax:817-468-7691
Practice Address - Street 1:817 W PIONEER PKWY
Practice Address - Street 2:SUITE 146B
Practice Address - City:GRAND PRAIRIE
Practice Address - State:TX
Practice Address - Zip Code:75051-4710
Practice Address - Country:US
Practice Address - Phone:972-522-5665
Practice Address - Fax:972-522-5605
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-04-26
Last Update Date:2011-06-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXPA01240261QP2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QP2300XAmbulatory Health Care FacilitiesClinic/CenterPrimary Care