Provider Demographics
NPI:1922639590
Name:CHRISTIAN NATIONAL CHURCH
Entity Type:Organization
Organization Name:CHRISTIAN NATIONAL CHURCH
Other - Org Name:THE FIRM
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OFFICER/PROVIDER
Authorized Official - Prefix:MR
Authorized Official - First Name:BRYANT
Authorized Official - Middle Name:LAMONT
Authorized Official - Last Name:BALL
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:425-387-7233
Mailing Address - Street 1:GENERAL DELIVERY
Mailing Address - Street 2:
Mailing Address - City:FULLERTON
Mailing Address - State:CA
Mailing Address - Zip Code:92834-9999
Mailing Address - Country:US
Mailing Address - Phone:425-387-7233
Mailing Address - Fax:
Practice Address - Street 1:1350 E CHAPMAN AVE
Practice Address - Street 2:
Practice Address - City:FULLERTON
Practice Address - State:CA
Practice Address - Zip Code:92834-7400
Practice Address - Country:US
Practice Address - Phone:425-387-7233
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2020-01-31
Last Update Date:2021-05-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207P00000XAllopathic & Osteopathic PhysiciansEmergency MedicineGroup - Single Specialty
No202C00000XAllopathic & Osteopathic PhysiciansIndependent Medical ExaminerGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA105384465Medicaid
CAD6785867Medicaid