Healthcare Provider Details

I. General information

NPI: 1003939711
Provider Name (Legal Business Name): SAN GORGONIO MEMORIAL HOSPITAL
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/09/2007
Last Update Date: 08/22/2020
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: 951-469-0431
Mailing address:
  • Phone: 951-845-1121
  • Fax: 951-469-0431

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code314000000X
TaxonomySkilled Nursing Facility
License NumberCA250001668
License Number StateCA

VIII. Authorized Official

Name: MR. JONATHAN BRENN
Title or Position: CEO
Credential:
Phone: 951-769-2100