Provider Demographics
NPI:1861732851
Name:MORNING GLORY HOUSE OF LOVE
Entity type:Organization
Organization Name:MORNING GLORY HOUSE OF LOVE
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:DIRECTORR/OWNER
Authorized Official - Prefix:MRS
Authorized Official - First Name:MYRTLE
Authorized Official - Middle Name:MARINA
Authorized Official - Last Name:PETERSON
Authorized Official - Suffix:
Authorized Official - Credentials:MASTERS
Authorized Official - Phone:772-672-1181
Mailing Address - Street 1:120 MAPLE AVE
Mailing Address - Street 2:SAME
Mailing Address - City:FORT PIERCE
Mailing Address - State:FL
Mailing Address - Zip Code:34982-3431
Mailing Address - Country:US
Mailing Address - Phone:772-672-1181
Mailing Address - Fax:772-489-7825
Practice Address - Street 1:120 MAPLE AVE
Practice Address - Street 2:SAME
Practice Address - City:FORT PIERCE
Practice Address - State:FL
Practice Address - Zip Code:34982-3431
Practice Address - Country:US
Practice Address - Phone:772-672-1181
Practice Address - Fax:772-489-7825
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2013-02-27
Last Update Date:2013-02-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL6905990251S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251S00000XAgenciesCommunity/Behavioral Health