1003967563 NPI number — EPHESIANS LIFE MINISTRIES

Table of content: (NPI 1003967563)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1003967563 NPI number — EPHESIANS LIFE MINISTRIES

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
EPHESIANS LIFE MINISTRIES
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1003967563
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
08/22/2020
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
1620 ELTON RD STE 204
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
SILVER SPRING
Provider Business Mailing Address State Name:
MD
Provider Business Mailing Address Postal Code:
20903-1760
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
301-439-7191
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
260 CEDAR LN SE # B
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
VIENNA
Provider Business Practice Location Address State Name:
VA
Provider Business Practice Location Address Postal Code:
22180-6698
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
703-204-0250
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
01/12/2007

Additional Information

Authorized Official

Authorized Official Last Name:
PARK
Authorized Official First Name:
SUNNY
Authorized Official Middle Name:
S
Authorized Official Title or Position:
THERAPIST
Authorized Official Telephone Number:
240-472-3216

Provider Taxonomy Codes

  • Taxonomy code: 101YM0800X , with the licence number:  11220 , registered in the state of MD ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 101YM0800X , with the licence number: 0904005471 , registered in the state of VA ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 7839381 . This is a "AETNA" identifier , issued by the state of ( MD ) . This identifiers is of the category "OTHER".
  • Identifier: 258321 . This is a "KAISER" identifier , issued by the state of ( MD ) . This identifiers is of the category "OTHER".
  • Identifier: 2133171 . This is a "MAMSI" identifier , issued by the state of ( MD ) . This identifiers is of the category "OTHER".
  • Identifier: 351252 . This is a "MHN" identifier , issued by the state of ( MD ) . This identifiers is of the category "OTHER".
  • Identifier: 633647 . This is a "NCPPO" identifier , issued by the state of ( MD ) . This identifiers is of the category "OTHER".




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