Provider Demographics
NPI:1689228884
Name:GREATER HARVEST COMMUNITY OUTREACH LIFE CENTER
Entity Type:Organization
Organization Name:GREATER HARVEST COMMUNITY OUTREACH LIFE CENTER
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:GERALD
Authorized Official - Middle Name:
Authorized Official - Last Name:EALEY
Authorized Official - Suffix:
Authorized Official - Credentials:DO,MS
Authorized Official - Phone:786-565-8377
Mailing Address - Street 1:17950 NW 22ND CT
Mailing Address - Street 2:
Mailing Address - City:MIAMI GARDENS
Mailing Address - State:FL
Mailing Address - Zip Code:33056-3706
Mailing Address - Country:US
Mailing Address - Phone:786-565-8377
Mailing Address - Fax:
Practice Address - Street 1:4888 NW 183RD ST STE 215
Practice Address - Street 2:
Practice Address - City:MIAMI GARDENS
Practice Address - State:FL
Practice Address - Zip Code:33055-2943
Practice Address - Country:US
Practice Address - Phone:954-591-0896
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2019-07-26
Last Update Date:2019-07-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QC1500XAmbulatory Health Care FacilitiesClinic/CenterCommunity Health