Healthcare Provider Details

I. General information

NPI: 1336505544
Provider Name (Legal Business Name): SAINT GABRIEL;S CHURCH O GOD IN CHRIST
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/05/2016
Last Update Date: 01/05/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5375 N 37TH ST
MILWAUKEE WI
53209-4729
US

IV. Provider business mailing address

5600 N STANTON DR
GLENDALE WI
53209-4341
US

V. Phone/Fax

Practice location:
  • Phone: 414-795-6397
  • Fax: 414-578-2862
Mailing address:
  • Phone: 414-795-6397
  • Fax: 414-578-2862

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QA0600X
TaxonomyAdult Day Care Clinic/Center
License Number
License Number State

VIII. Authorized Official

Name: MR. LEE A. SHAW
Title or Position: ADMINISTRATOR
Credential:
Phone: 414-795-6397