MEDICARE: HEALING WATERS FAMILY ENRICHMENT CENTER

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	252Y00000X	Early Intervention Provider Agency

General Provider Information

NPI Number	:	1376996777
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	HEALING WATERS FAMILY ENRICHMENT CENTER

Provider Business Mailing Address
First Line	:	4312 N 76TH ST
Second Line	:	APT A
City	:	MILWAUKEE
State	:	WI
Zip	:	53222-2043
Country	:	US
Telephone Number	:	414-499-8463
Fax Number	:

Provider Business Practice Location Address
First Line	:	4312 N 76TH ST
Second Line	:	4
City	:	MILWAUKEE
State	:	WI
Zip	:	53222-2043
Country	:	US
Telephone Number	:	414-499-8463
Fax Number	:

Authorized Official
Title or Position	:	OWNER
Name	:	KELLY DANIELLE COLEMAN
Credential	:
Telephone Number	:	414-499-8463

Provider Enumeration Date	:	07/20/2016
Last Update Date	:	07/20/2016

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