Provider Demographics
NPI:1124352281
Name:CHURCH OF THE LIVING GOD PGT
Entity type:Organization
Organization Name:CHURCH OF THE LIVING GOD PGT
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:PASTOR
Authorized Official - Prefix:MR
Authorized Official - First Name:CHARLES
Authorized Official - Middle Name:CLEVELAND
Authorized Official - Last Name:JUNIOR
Authorized Official - Suffix:
Authorized Official - Credentials:MINISTER
Authorized Official - Phone:214-372-3369
Mailing Address - Street 1:2610 E LEDBETTER DR
Mailing Address - Street 2:P O BOX 41485
Mailing Address - City:DALLAS
Mailing Address - State:TX
Mailing Address - Zip Code:75216-7404
Mailing Address - Country:US
Mailing Address - Phone:214-372-3369
Mailing Address - Fax:
Practice Address - Street 1:2610 E LEDBETTER DR
Practice Address - Street 2:2610 E LEDBETTER DRIVE
Practice Address - City:DALLAS
Practice Address - State:TX
Practice Address - Zip Code:75216-7404
Practice Address - Country:US
Practice Address - Phone:214-372-3369
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-09-22
Last Update Date:2009-09-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes343900000XTransportation ServicesNon-emergency Medical Transport (VAN)
No251C00000XAgenciesDay Training, Developmentally Disabled Services