Healthcare Provider Details

I. General information

NPI: 1629513775
Provider Name (Legal Business Name): VESSELS OF GOD
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/28/2016
Last Update Date: 12/28/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2821 N 4TH ST # 304
MILWAUKEE WI
53212-2362
US

IV. Provider business mailing address

2821 N 4TH ST # 304
MILWAUKEE WI
53212-2362
US

V. Phone/Fax

Practice location:
  • Phone: 312-888-6803
  • Fax:
Mailing address:
  • Phone: 312-888-6803
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code251V00000X
TaxonomyVoluntary or Charitable Agency
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code320800000X
TaxonomyMental Illness Community Based Residential Treatment Facility
License Number
License Number State

VIII. Authorized Official

Name: MR. LAMARR LOVE
Title or Position: PRESIDENT
Credential:
Phone: 312-888-6803