Healthcare Provider Details

I. General information

NPI: 1780805721
Provider Name (Legal Business Name): UNIVERSAL LIFE CHURCH INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/01/2007
Last Update Date: 08/22/2020
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

382 BAY ST SUITE #0102
STATEN ISLAND NY
10301-0102
US

IV. Provider business mailing address

PO BOX 0891 KABBALAH VISITING NURSES ASSOCIATION PO
STATEN ISLAND NY
10314-0891
US

V. Phone/Fax

Practice location:
  • Phone: 718-720-0292
  • Fax: 718-761-5562
Mailing address:
  • Phone: 718-720-0292
  • Fax: 718-761-5562

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code282J00000X
TaxonomyReligious Nonmedical Health Care Institution
License Number719468
License Number StateFL
# 2
Primary TaxonomyY
Taxonomy Code282J00000X
TaxonomyReligious Nonmedical Health Care Institution
License NumberA858936
License Number StateNY

VIII. Authorized Official

Name: DR. RODOLFO A NICHOLSON JR.
Title or Position: PRESIDENT & CHIEF CLERGY
Credential: MD
Phone: 646-266-4010