Healthcare Provider Details

I. General information

NPI: 1396990826
Provider Name (Legal Business Name): EVANGEL STREET & BYWAY MINISTRIES
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/25/2008
Last Update Date: 11/26/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

12732 LORETTO ST
DETROIT MI
48205-3941
US

IV. Provider business mailing address

12732 LORETTO ST
DETROIT MI
48205-3941
US

V. Phone/Fax

Practice location:
  • Phone: 313-371-1404
  • Fax: 313-371-1404
Mailing address:
  • Phone: 313-371-1404
  • Fax: 313-371-1404

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code347C00000X
TaxonomyPrivate Vehicle
License Number560428014298
License Number StateMI

VIII. Authorized Official

Name: MR. JOHNNY MONROE
Title or Position: PRESIDENT
Credential:
Phone: 313-717-2513