Provider Demographics
NPI:1629322367
Name:TEMPLE OF THE LORD OUTREACH MINISTRIES INC.
Entity Type:Organization
Organization Name:TEMPLE OF THE LORD OUTREACH MINISTRIES INC.
Other - Org Name:AGAPE HOUSE
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:MR
Authorized Official - First Name:DENNIS
Authorized Official - Middle Name:
Authorized Official - Last Name:GRAY
Authorized Official - Suffix:III
Authorized Official - Credentials:
Authorized Official - Phone:702-682-9225
Mailing Address - Street 1:PO BOX 94091
Mailing Address - Street 2:
Mailing Address - City:LAS VEGAS
Mailing Address - State:NV
Mailing Address - Zip Code:89193-4091
Mailing Address - Country:US
Mailing Address - Phone:702-682-9225
Mailing Address - Fax:702-475-6845
Practice Address - Street 1:94 ANCIENT HILLS LN
Practice Address - Street 2:
Practice Address - City:HENDERSON
Practice Address - State:NV
Practice Address - Zip Code:89074-1750
Practice Address - Country:US
Practice Address - Phone:702-682-9225
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:TEMPLE OF THE LORD OUTREACH MINISTRIES INC.62866637
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2012-11-02
Last Update Date:2012-11-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NVNV20051605735101Y00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes101Y00000XBehavioral Health & Social Service ProvidersCounselorGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NV1740564699Medicaid