=====================================================
General NPI Number Information
=====================================================
NPI Number | 1528200458
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | MAKE THAT CHANGE MINISTRY OUTREACH CHURCH
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 03/24/2009
-----------------------------------------------------
Last Update Date | 03/24/2009
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 11170 HAWTHORNE
-----------------------------------------------------
City | SOUTHGATE
-----------------------------------------------------
State | MI
-----------------------------------------------------
Zip | 48195-8540
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 313-549-6059
-----------------------------------------------------
Fax | 313-305-4316
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 3044 CORTLAND ST
-----------------------------------------------------
City | DETROIT
-----------------------------------------------------
State | MI
-----------------------------------------------------
Zip | 48206-3400
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 313-549-6059
-----------------------------------------------------
Fax | 313-305-4316
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | CEO
-----------------------------------------------------
Name | MR. TONY SMITH
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 313-549-6059
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 251V00000X
-----------------------------------------------------
Taxonomy Name | Voluntary or Charitable Agency
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------