MEDICARE: EVANGEL STREET & BYWAY MINISTRIES

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	347C00000X	Private Vehicle	560428014298	MI

General Provider Information

NPI Number	:	1396990826
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	EVANGEL STREET & BYWAY MINISTRIES

Provider Business Mailing Address
First Line	:	12732 LORETTO ST
Second Line	:
City	:	DETROIT
State	:	MI
Zip	:	48205-3941
Country	:	US
Telephone Number	:	313-371-1404
Fax Number	:	313-371-1404

Provider Business Practice Location Address
First Line	:	12732 LORETTO ST
Second Line	:
City	:	DETROIT
State	:	MI
Zip	:	48205-3941
Country	:	US
Telephone Number	:	313-371-1404
Fax Number	:	313-371-1404

Authorized Official
Title or Position	:	PRESIDENT
Name	:	MR. JOHNNY MONROE
Credential	:
Telephone Number	:	313-717-2513

Provider Enumeration Date	:	11/25/2008
Last Update Date	:	11/26/2008

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Directions to “EVANGEL STREET & BYWAY MINISTRIES ” Practice Location

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