Provider Demographics
NPI:1770834467
Name:INTERDENOMINATIONAL CHURCH OF CHRISTIAN LOVE, INC
Entity Type:Organization
Organization Name:INTERDENOMINATIONAL CHURCH OF CHRISTIAN LOVE, INC
Other - Org Name:ST MARTIN'S FAMILY SERVICES
Other - Org Type:Doing Business As
Authorized Official - Title/Position:FOUNDER
Authorized Official - Prefix:DR
Authorized Official - First Name:ROGER
Authorized Official - Middle Name:
Authorized Official - Last Name:PUMPHREY
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:414-961-1614
Mailing Address - Street 1:6310 N PORT WASHINGTON RD
Mailing Address - Street 2:
Mailing Address - City:GLENDALE
Mailing Address - State:WI
Mailing Address - Zip Code:53217-4300
Mailing Address - Country:US
Mailing Address - Phone:414-961-1614
Mailing Address - Fax:414-961-1616
Practice Address - Street 1:6310 N PORT WASHINGTON RD
Practice Address - Street 2:
Practice Address - City:GLENDALE
Practice Address - State:WI
Practice Address - Zip Code:53217-4300
Practice Address - Country:US
Practice Address - Phone:414-961-1614
Practice Address - Fax:414-961-1616
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-09-21
Last Update Date:2012-10-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251E00000XAgenciesHome Health