MEDICARE: VICTORY UNTO SALVATION FAITH MINISTRIES DBA THE PHILIP HOUSE MISSION

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	320800000X	Mental Illness Community Based Residential Treatment Facility	SA0823215	MI
2	324500000X	Substance Abuse Rehabilitation Facility	SA0823215	MI

General Provider Information

NPI Number	:	1306257852
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	VICTORY UNTO SALVATION FAITH MINISTRIES DBA THE PHILIP HOUSE MISSION

Provider Business Mailing Address
First Line	:	18066 JAMES COUZENS FWY
Second Line	:
City	:	DETROIT
State	:	MI
Zip	:	48235-2646
Country	:	US
Telephone Number	:	313-828-2202
Fax Number	:

Provider Business Practice Location Address
First Line	:	18066 JAMES COUZENS FWY
Second Line	:	2305 PASADENA
City	:	DETROIT
State	:	MI
Zip	:	48235-2646
Country	:	US
Telephone Number	:	313-828-2202
Fax Number	:

Authorized Official
Title or Position	:	EXECUTIVE DIRECTOR
Name	:	MS. KARRIE A BROWN
Credential	:
Telephone Number	:	313-828-2202

Provider Enumeration Date	:	05/17/2014
Last Update Date	:	01/26/2015

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