MEDICARE: SUCCESSFUL BUILDING OUTREACH MINISTRY CHURCH

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	251V00000X	Voluntary or Charitable Agency

General Provider Information

NPI Number	:	1730415662
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	SUCCESSFUL BUILDING OUTREACH MINISTRY CHURCH

Provider Business Mailing Address
First Line	:	3187 MANGROVE DR
Second Line	:
City	:	STERLING HEIGHTS
State	:	MI
Zip	:	48314-4409
Country	:	US
Telephone Number	:	248-761-6170
Fax Number	:

Provider Business Practice Location Address
First Line	:	3187 MANGROVE DR
Second Line	:
City	:	STERLING HEIGHTS
State	:	MI
Zip	:	48314-4409
Country	:	US
Telephone Number	:	248-761-6170
Fax Number	:

Authorized Official
Title or Position	:	DIRECTOR
Name	:	MR. ROBERT PAUL BLACK
Credential	:
Telephone Number	:	248-761-6170

Provider Enumeration Date	:	10/28/2009
Last Update Date	:	10/28/2009

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