MEDICARE: THE SABAOTH GROUP, INC.

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	251S00000X	Community/Behavioral Health Agency
2	251B00000X	Case Management Agency

General Provider Information

NPI Number	:	1841556768
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	THE SABAOTH GROUP, INC.

Provider Business Mailing Address
First Line	:	774 ROCKAWAY AVE
Second Line	:
City	:	BROOKLYN
State	:	NY
Zip	:	11212-5807
Country	:	US
Telephone Number	:	718-676-4020
Fax Number	:	718-676-4019

Provider Business Practice Location Address
First Line	:	774 ROCKAWAY AVE
Second Line	:
City	:	BROOKLYN
State	:	NY
Zip	:	11212-5807
Country	:	US
Telephone Number	:	718-676-4020
Fax Number	:	718-676-4019

Authorized Official
Title or Position	:	EXECUTIVE DIRECTOR
Name	:	MR. DENNIS TAYLOR
Credential	:
Telephone Number	:	718-216-2643

Provider Enumeration Date	:	04/04/2012
Last Update Date	:	04/04/2012

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