Provider Demographics
NPI:1356695480
Name:SHACKLEFREE MINISTRIES
Entity type:Organization
Organization Name:SHACKLEFREE MINISTRIES
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CHRISTIAN COUNSELOR
Authorized Official - Prefix:MRS
Authorized Official - First Name:VIRGINIA
Authorized Official - Middle Name:LEA
Authorized Official - Last Name:TAYLOR
Authorized Official - Suffix:
Authorized Official - Credentials:BCLBT
Authorized Official - Phone:903-917-6632
Mailing Address - Street 1:409 N FREDONIA ST
Mailing Address - Street 2:SUITE 116
Mailing Address - City:LONGVIEW
Mailing Address - State:TX
Mailing Address - Zip Code:75601-6466
Mailing Address - Country:US
Mailing Address - Phone:903-917-6632
Mailing Address - Fax:
Practice Address - Street 1:409 N FREDONIA ST
Practice Address - Street 2:SUITE 116
Practice Address - City:LONGVIEW
Practice Address - State:TX
Practice Address - Zip Code:75601-6466
Practice Address - Country:US
Practice Address - Phone:903-917-6632
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-10-26
Last Update Date:2012-10-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes320900000XResidential Treatment FacilitiesCommunity Based Residential Treatment Facility, Intellectual and/or Developmental Disabilities