Provider Demographics
NPI:1619195740
Name:WATER OF LIFE COMMUNITY OUTREACH
Entity Type:Organization
Organization Name:WATER OF LIFE COMMUNITY OUTREACH
Other - Org Name:WELL OF HEALING MOBILE MEDICAL CLINIC
Other - Org Type:Doing Business As
Authorized Official - Title/Position:ADMINISTRATOR
Authorized Official - Prefix:MRS
Authorized Official - First Name:ANGELA
Authorized Official - Middle Name:
Authorized Official - Last Name:COASTON
Authorized Official - Suffix:
Authorized Official - Credentials:RN
Authorized Official - Phone:909-463-0103
Mailing Address - Street 1:7623 EAST AVE
Mailing Address - Street 2:
Mailing Address - City:FONTANA
Mailing Address - State:CA
Mailing Address - Zip Code:92336-2901
Mailing Address - Country:US
Mailing Address - Phone:909-463-0103
Mailing Address - Fax:909-463-4840
Practice Address - Street 1:7623 EAST AVE
Practice Address - Street 2:
Practice Address - City:FONTANA
Practice Address - State:CA
Practice Address - Zip Code:92336-2901
Practice Address - Country:US
Practice Address - Phone:909-463-0103
Practice Address - Fax:909-463-4840
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-04-23
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA251S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251S00000XAgenciesCommunity/Behavioral Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
CACMM71071FMedicaid