Provider Demographics
NPI:1952682247
Name:BREAKTHROUGH REVIVAL PENTECOSTAL HOLINESS CHURCH
Entity Type:Organization
Organization Name:BREAKTHROUGH REVIVAL PENTECOSTAL HOLINESS CHURCH
Other - Org Name:BREAKTHROUGH REVIVAL CENTER CHURCH, INC.
Other - Org Type:Former Legal Business Name
Authorized Official - Title/Position:ADMINISTRATOR
Authorized Official - Prefix:MRS
Authorized Official - First Name:LYDIA
Authorized Official - Middle Name:K
Authorized Official - Last Name:JONES
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:252-985-1875
Mailing Address - Street 1:PO BOX 31026
Mailing Address - Street 2:
Mailing Address - City:GREENVILLE
Mailing Address - State:NC
Mailing Address - Zip Code:27833-1026
Mailing Address - Country:US
Mailing Address - Phone:252-985-1875
Mailing Address - Fax:252-399-0526
Practice Address - Street 1:210 CHURCH ST
Practice Address - Street 2:
Practice Address - City:GREENVILLE
Practice Address - State:NC
Practice Address - Zip Code:27834-1212
Practice Address - Country:US
Practice Address - Phone:252-985-1875
Practice Address - Fax:252-399-0526
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-08-31
Last Update Date:2011-08-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251B00000XAgenciesCase Management
No251S00000XAgenciesCommunity/Behavioral Health