MEDICARE: THE EDGE COMMUNITY CHURCH OF SUISUN

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy
1	171M00000X	Case Manager/Care Coordinator
2	251B00000X	Case Management Agency
3	251X00000X	Supports Brokerage Agency
4	251V00000X	Voluntary or Charitable Agency

General Provider Information

NPI Number	:	1508549668
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	THE EDGE COMMUNITY CHURCH OF SUISUN

Provider Business Mailing Address
First Line	:	PO BOX 2404
Second Line	:
City	:	SUISUN CITY
State	:	CA
Zip	:	94585-5404
Country	:	US
Telephone Number	:	707-438-8213
Fax Number	:

Provider Business Practice Location Address
First Line	:	2166 SACRAMENTO ST
Second Line	:
City	:	VALLEJO
State	:	CA
Zip	:	94590-3126
Country	:	US
Telephone Number	:	707-435-3995
Fax Number	:

Authorized Official
Title or Position	:	EXECUTIVE ADMIN
Name	:	GERMAINE LUCIANO
Credential	:	BA
Telephone Number	:	707-438-8213

Provider Enumeration Date	:	08/07/2023
Last Update Date	:	08/07/2023

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Directions to “THE EDGE COMMUNITY CHURCH OF SUISUN ” Practice Location

Language	Start Address	Practice Location

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