MEDICARE: NEW HOPE CHURCH OF GOD IN CHRIST

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
2	251S00000X	Community/Behavioral Health Agency

General Provider Information

NPI Number	:	1790110013
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	NEW HOPE CHURCH OF GOD IN CHRIST

Provider Business Mailing Address
First Line	:	1710 N 33RD ST
Second Line	:
City	:	MILWAUKEE
State	:	WI
Zip	:	53208-1904
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	1710 N 33RD ST
Second Line	:
City	:	MILWAUKEE
State	:	WI
Zip	:	53208-1904
Country	:	US
Telephone Number	:	414-377-7956
Fax Number	:

Authorized Official
Title or Position	:	EXECUTIVE DIRECTOR
Name	:	LEON DAVIS
Credential	:
Telephone Number	:	414-377-7956

Provider Enumeration Date	:	09/05/2013
Last Update Date	:	09/05/2013

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