Healthcare Provider Details

I. General information

NPI: 1285598243
Provider Name (Legal Business Name): BLOOMINGTON PENTECOSTAL CHURCH OF GOD
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/15/2025
Last Update Date: 12/15/2025
Certification Date: 12/14/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

585 LYTLE CREEK RD
LYTLE CREEK CA
92358-9758
US

IV. Provider business mailing address

PO BOX 158
LYTLE CREEK CA
92358-0158
US

V. Phone/Fax

Practice location:
  • Phone: 909-900-6011
  • Fax:
Mailing address:
  • Phone: 909-900-6011
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code171M00000X
TaxonomyCase Manager/Care Coordinator
License Number
License Number State

VIII. Authorized Official

Name: JOHN DEATHERAGE
Title or Position: PASTOR
Credential: ORDAINED
Phone: 909-900-6011