1699307173 NPI number — KINGDOM OUTREACH CENTER OF SAN ANTONIO, TX

Table of Contents

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1699307173 NPI number — KINGDOM OUTREACH CENTER OF SAN ANTONIO, TX

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
KINGDOM OUTREACH CENTER OF SAN ANTONIO, TX
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:
1699307173
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
02/12/2020
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
6027 RED ROSE
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
SAN ANTONIO
Provider Business Mailing Address State Name:
TX
Provider Business Mailing Address Postal Code:
78244-4431
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
KINGDOM OUT REACH CENTER OF SAN ANTONIO
Provider Second Line Business Practice Location Address:
3819 NACO PERRIN BLVD #118
Provider Business Practice Location Address City Name:
SAN ANTONIO
Provider Business Practice Location Address State Name:
TX
Provider Business Practice Location Address Postal Code:
78217
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
210-687-9715
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
02/12/2020

Additional Information

Authorized Official

Authorized Official Last Name:
BROWN
Authorized Official First Name:
KENNETH
Authorized Official Middle Name:
Authorized Official Title or Position:
LEAD CONSULTANT
Authorized Official Telephone Number:
210-687-9715

Provider Taxonomy Codes

  • Taxonomy code: 101Y00000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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





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