Healthcare Provider Details

I. General information

NPI: 1568469997
Provider Name (Legal Business Name): SAN GORGONIO MEMORIAL HOSPITAL
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/30/2005
Last Update Date: 11/13/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

600 N HIGHLAND SPRINGS AVE
BANNING CA
92220-3046
US

IV. Provider business mailing address

600 N HIGHLAND SPRINGS AVE
BANNING CA
92220-3046
US

V. Phone/Fax

Practice location:
  • Phone: 951-845-1121
  • Fax: 951-769-0431
Mailing address:
  • Phone: 951-845-1121
  • Fax: 951-769-0431

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code282N00000X
TaxonomyGeneral Acute Care Hospital
License Number250001199
License Number StateCA

VIII. Authorized Official

Name: MS. MAYDA L. BROWN
Title or Position: DIRECTOR PT. FIN. SVC.
Credential:
Phone: 951-769-2170