=====================================================
General NPI Number Information
=====================================================
NPI Number | 1386181329
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | GOD'S WORD BIBLE CHURCH
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 01/29/2017
-----------------------------------------------------
Last Update Date | 02/08/2017
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1513 SPORTS DR STE 350
-----------------------------------------------------
City | SACRAMENTO
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 95834-1903
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 916-696-2511
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 2701 DEL PASO RD # 130-250
-----------------------------------------------------
City | SACRAMENTO
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 95835-2305
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 916-696-2511
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | PASTOR/PRESIDENT: COUNSELOR
-----------------------------------------------------
Name | MR. MARK A YANCY
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 916-914-5012
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 251T00000X
-----------------------------------------------------
Taxonomy Name | PACE Provider Organization
-----------------------------------------------------
License Number | AII15590316
-----------------------------------------------------
License Number State | CA
-----------------------------------------------------