Provider Demographics
NPI:1780127589
Name:FAITH CHRISTIAN MINISTRY NON-DENOMINATIONAL CHURCH INC.
Entity type:Organization
Organization Name:FAITH CHRISTIAN MINISTRY NON-DENOMINATIONAL CHURCH INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PASTOR/PASTORAL COUNSELOR
Authorized Official - Prefix:DR
Authorized Official - First Name:MONA
Authorized Official - Middle Name:JUANITA
Authorized Official - Last Name:PETERSON-OMOTOLA
Authorized Official - Suffix:
Authorized Official - Credentials:REV DR PHD
Authorized Official - Phone:866-720-5321
Mailing Address - Street 1:7306 SUMMERTREE DR
Mailing Address - Street 2:
Mailing Address - City:NORTH CHESTERFIELD
Mailing Address - State:VA
Mailing Address - Zip Code:23234-5935
Mailing Address - Country:US
Mailing Address - Phone:866-720-5321
Mailing Address - Fax:
Practice Address - Street 1:7400 BEAUFONT SPRINGS DRIVE SUITE 300
Practice Address - Street 2:
Practice Address - City:RICHMOND,
Practice Address - State:VA
Practice Address - Zip Code:23225
Practice Address - Country:US
Practice Address - Phone:866-720-5321
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-11-28
Last Update Date:2016-11-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA14946305R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes305R00000XManaged Care OrganizationsPreferred Provider Organization