Healthcare Provider Details

I. General information

NPI: 1457697096
Provider Name (Legal Business Name): COALITION FOR COMMUNITY EMPOWERMENT
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/01/2013
Last Update Date: 01/02/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4706 W CAPITOL DR
MILWAUKEE WI
53216-1535
US

IV. Provider business mailing address

4706 W CAPITOL DR
MILWAUKEE WI
53216-1535
US

V. Phone/Fax

Practice location:
  • Phone: 414-377-1927
  • Fax:
Mailing address:
  • Phone: 414-377-1927
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code133NN1002X
TaxonomyNutrition Education Nutritionist
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code343900000X
TaxonomyNon-emergency Medical Transport (VAN)
License Number
License Number State
# 3
Primary TaxonomyY
Taxonomy Code251300000X
TaxonomyLocal Education Agency (LEA)
License Number
License Number State

VIII. Authorized Official

Name: DEMETRIOUS HENDERSON
Title or Position: DIRECTOR
Credential:
Phone: 414-377-1927