Healthcare Provider Details

I. General information

NPI: 1417201427
Provider Name (Legal Business Name): ABUNDANT BLESSINGS COMMUNITY OUTREACH SARVICES INC.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/30/2012
Last Update Date: 12/17/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

216 E GARFIELD AVE
MILWAUKEE WI
53212-3302
US

IV. Provider business mailing address

216 E GARFIELD AVE
MILWAUKEE WI
53212-3302
US

V. Phone/Fax

Practice location:
  • Phone: 414-562-2208
  • Fax: 414-395-3794
Mailing address:
  • Phone: 414-562-2208
  • Fax: 414-395-3794

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code252Y00000X
TaxonomyEarly Intervention Provider Agency
License Number28807-031
License Number StateWI
# 2
Primary TaxonomyY
Taxonomy Code251B00000X
TaxonomyCase Management Agency
License Number
License Number State

VIII. Authorized Official

Name: MRS. STINA BAKER
Title or Position: PRESIDENT
Credential: LPN
Phone: 414-562-2208