Organization
BLOOMINGTON PENTECOSTAL CHURCH OF GOD
Active
Organization subpart
No
Provider details
NPI number
Authorized official
JOHN DEATHERAGE ORDAINED (PASTOR)
(909) 900-6011
Entity
Organization
Contact information
Practice address
585 LYTLE CREEK RD, LYTLE CREEK, CA 92358-9758
(909) 900-6011
Mailing address
PO BOX 158, LYTLE CREEK, CA 92358-0158
(909) 900-6011
Taxonomy
Speciality
Code
Description
License number
State
171M00000X
Case Manager/Care Coordinator
Primary
—
—
Other
Enumeration date
12/15/2025
Last updated
12/15/2025
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