=====================================================
General NPI Number Information
=====================================================
NPI Number | 1740680636
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | INFINITY CHRISTIAN COMMUNITY ORGANIZATION
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 08/27/2014
-----------------------------------------------------
Last Update Date | 08/27/2014
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 6188 N DENMARK ST
-----------------------------------------------------
City | MILWAUKEE
-----------------------------------------------------
State | WI
-----------------------------------------------------
Zip | 53225-1644
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 414-243-4938
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 1224 N 46TH ST
-----------------------------------------------------
City | MILWAUKEE
-----------------------------------------------------
State | WI
-----------------------------------------------------
Zip | 53208-2739
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 414-243-4938
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | EXECUTIVE DIRECTOR
-----------------------------------------------------
Name | MRS. MARIA VENZANT
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 414-243-4938
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 251B00000X
-----------------------------------------------------
Taxonomy Name | Case Management Agency
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------