Provider Demographics
NPI:1972733053
Name:REACHING OUT MINISTRIES
Entity type:Organization
Organization Name:REACHING OUT MINISTRIES
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT/PRIMARY DENTAL PROVIDER
Authorized Official - Prefix:DR
Authorized Official - First Name:KENNY
Authorized Official - Middle Name:WAYNE
Authorized Official - Last Name:BOURGEOIS
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:671-646-2010
Mailing Address - Street 1:226 CHALAN SAN ANTONIO STE C
Mailing Address - Street 2:AMPARO'S BUSINESS CENTER
Mailing Address - City:TAMUNING
Mailing Address - State:GU
Mailing Address - Zip Code:96913-3525
Mailing Address - Country:US
Mailing Address - Phone:671-646-2010
Mailing Address - Fax:671-646-2070
Practice Address - Street 1:226 CHALAN SAN ANTONIO STE C
Practice Address - Street 2:AMPARO'S BUSINESS CENTER
Practice Address - City:TAMUNING
Practice Address - State:GU
Practice Address - Zip Code:96913-3525
Practice Address - Country:US
Practice Address - Phone:671-646-2010
Practice Address - Fax:671-646-2070
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-07-22
Last Update Date:2009-07-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GUD927261QD0000X
TX14605261QD0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QD0000XAmbulatory Health Care FacilitiesClinic/CenterDental