Provider Demographics
NPI:1659082063
Name:SOULED OUT REACH MINISTRY
Entity Type:Organization
Organization Name:SOULED OUT REACH MINISTRY
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:
Authorized Official - First Name:GLORIA
Authorized Official - Middle Name:SAMANTHA
Authorized Official - Last Name:COUNCIL
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:704-492-8899
Mailing Address - Street 1:545 MOSS STREAM LN
Mailing Address - Street 2:
Mailing Address - City:CHARLOTTE
Mailing Address - State:NC
Mailing Address - Zip Code:28214-8846
Mailing Address - Country:US
Mailing Address - Phone:704-492-8899
Mailing Address - Fax:
Practice Address - Street 1:2241B BEATTIES FORD RD
Practice Address - Street 2:
Practice Address - City:CHARLOTTE
Practice Address - State:NC
Practice Address - Zip Code:28216-4311
Practice Address - Country:US
Practice Address - Phone:704-492-8899
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2022-12-06
Last Update Date:2022-12-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251S00000XAgenciesCommunity/Behavioral Health