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General NPI Number Information
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NPI Number | 1396990826
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Entity Type | Organization
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Legal Business Name | EVANGEL STREET & BYWAY MINISTRIES
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Dates
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Enumeration Date | 11/25/2008
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Last Update Date | 11/26/2008
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Provider Practice Location Address
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Address Line | 12732 LORETTO ST
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City | DETROIT
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State | MI
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Zip | 48205-3941
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Country | US
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Telephone | 313-371-1404
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Fax | 313-371-1404
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Provider Business Mailing Address
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Address Line | 12732 LORETTO ST
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City | DETROIT
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State | MI
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Zip | 48205-3941
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Country | US
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Telephone | 313-371-1404
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Fax | 313-371-1404
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Authorized Official
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Title or Position | PRESIDENT
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Name | MR. JOHNNY MONROE
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Credential |
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Telephone | 313-717-2513
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 347C00000X
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Taxonomy Name | Private Vehicle
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License Number | 560428014298
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License Number State | MI
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