Provider Demographics
NPI:1952118051
Name:MNODERN ECCLESIA
Entity type:Organization
Organization Name:MNODERN ECCLESIA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DIRECTOR
Authorized Official - Prefix:MR
Authorized Official - First Name:WILLIE
Authorized Official - Middle Name:J
Authorized Official - Last Name:SINGLETON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:573-447-9049
Mailing Address - Street 1:PO BOX 262
Mailing Address - Street 2:
Mailing Address - City:CARUTHERSVILLE
Mailing Address - State:MO
Mailing Address - Zip Code:63830-0262
Mailing Address - Country:US
Mailing Address - Phone:573-497-0490
Mailing Address - Fax:
Practice Address - Street 1:597 SAN PABLO DR
Practice Address - Street 2:
Practice Address - City:STONE MOUNTAIN
Practice Address - State:GA
Practice Address - Zip Code:30083-3855
Practice Address - Country:US
Practice Address - Phone:573-479-0490
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2024-12-12
Last Update Date:2024-12-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes101Y00000XBehavioral Health & Social Service ProvidersCounselorGroup - Multi-Specialty