Provider Demographics
NPI:1205667524
Name:WATER OF LIFE COMMUNITY CHURCH
Entity type:Organization
Organization Name:WATER OF LIFE COMMUNITY CHURCH
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:EXECUTIVE DIRECTOR OF OPERATIONS
Authorized Official - Prefix:
Authorized Official - First Name:JIM
Authorized Official - Middle Name:
Authorized Official - Last Name:KENSINGER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:909-463-3915
Mailing Address - Street 1:14418 MILLER AVE STE K
Mailing Address - Street 2:
Mailing Address - City:FONTANA
Mailing Address - State:CA
Mailing Address - Zip Code:92336-4265
Mailing Address - Country:US
Mailing Address - Phone:909-803-1059
Mailing Address - Fax:
Practice Address - Street 1:8440 NUEVO AVE
Practice Address - Street 2:
Practice Address - City:FONTANA
Practice Address - State:CA
Practice Address - Zip Code:92335-3824
Practice Address - Country:US
Practice Address - Phone:909-803-1059
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2024-08-08
Last Update Date:2024-08-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes171M00000XOther Service ProvidersCase Manager/Care CoordinatorGroup - Single Specialty