Provider Demographics
NPI:1437510542
Name:CITY CHURCH 242
Entity Type:Organization
Organization Name:CITY CHURCH 242
Other - Org Name:CITY CHURCH LIVE IN CENTER
Other - Org Type:Doing Business As
Authorized Official - Title/Position:EXECUTIVE DIRECTOR / PASTOR
Authorized Official - Prefix:MR
Authorized Official - First Name:SCOTT
Authorized Official - Middle Name:
Authorized Official - Last Name:MULVEY
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:707-426-2172
Mailing Address - Street 1:743 E TABOR AVE
Mailing Address - Street 2:
Mailing Address - City:FAIRFIELD
Mailing Address - State:CA
Mailing Address - Zip Code:94533-4046
Mailing Address - Country:US
Mailing Address - Phone:707-426-2172
Mailing Address - Fax:
Practice Address - Street 1:743 E TABOR AVE
Practice Address - Street 2:
Practice Address - City:FAIRFIELD
Practice Address - State:CA
Practice Address - Zip Code:94533-4046
Practice Address - Country:US
Practice Address - Phone:707-426-2172
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:GRACE INTERNATIONAL MINISTRIES
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2016-03-16
Last Update Date:2016-03-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA324500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes324500000XResidential Treatment FacilitiesSubstance Abuse Rehabilitation Facility