1730150657 NPI number — MISSIONARY BAPTIST FOUNDATION OF AMERICA, INC

Table of content: (NPI 1730150657)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1730150657 NPI number — MISSIONARY BAPTIST FOUNDATION OF AMERICA, INC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
MISSIONARY BAPTIST FOUNDATION OF AMERICA, INC
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:
6
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:
1730150657
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:
1212 13TH ST
Provider Second Line Business Mailing Address:
SUITE 100
Provider Business Mailing Address City Name:
LUBBOCK
Provider Business Mailing Address State Name:
TX
Provider Business Mailing Address Postal Code:
79401-3940
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
806-747-3447
Provider Business Mailing Address Fax Number:
806-747-1632

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1003 LOOP RD
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
ALPINE
Provider Business Practice Location Address State Name:
TX
Provider Business Practice Location Address Postal Code:
79830-3229
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
432-837-3343
Provider Business Practice Location Address Fax Number:
806-837-7076
Provider Enumeration Date:
01/30/2006

Additional Information

Authorized Official

Authorized Official Last Name:
RICE
Authorized Official First Name:
SARAH
Authorized Official Middle Name:
B
Authorized Official Title or Position:
DIRECTOR OF OPERATIONS
Authorized Official Telephone Number:
806-747-3447

Provider Taxonomy Codes

  • Taxonomy code: 313M00000X , with the licence number:  15657 , registered in the state of TX ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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





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