Provider Demographics
NPI:1336505544
Name:SAINT GABRIEL;S CHURCH O GOD IN CHRIST
Entity Type:Organization
Organization Name:SAINT GABRIEL;S CHURCH O GOD IN CHRIST
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:ADMINISTRATOR
Authorized Official - Prefix:MR
Authorized Official - First Name:LEE
Authorized Official - Middle Name:A
Authorized Official - Last Name:SHAW
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:414-795-6397
Mailing Address - Street 1:5600 N STANTON DR
Mailing Address - Street 2:
Mailing Address - City:GLENDALE
Mailing Address - State:WI
Mailing Address - Zip Code:53209-4341
Mailing Address - Country:US
Mailing Address - Phone:414-795-6397
Mailing Address - Fax:414-578-2862
Practice Address - Street 1:5375 N 37TH ST
Practice Address - Street 2:
Practice Address - City:MILWAUKEE
Practice Address - State:WI
Practice Address - Zip Code:53209-4729
Practice Address - Country:US
Practice Address - Phone:414-795-6397
Practice Address - Fax:414-578-2862
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-01-05
Last Update Date:2016-01-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QA0600XAmbulatory Health Care FacilitiesClinic/CenterAdult Day Care