Healthcare Provider Details

I. General information

NPI: 1801605621
Provider Name (Legal Business Name): SAN BERNARDINO COUNTY
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/06/2025
Last Update Date: 01/06/2025
Certification Date: 01/06/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

400 N PEPPER AVE
COLTON CA
92324-1819
US

IV. Provider business mailing address

400 N PEPPER AVE
COLTON CA
92324-1819
US

V. Phone/Fax

Practice location:
  • Phone: 909-777-0730
  • Fax:
Mailing address:
  • Phone: 909-777-0730
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number
License Number State

VIII. Authorized Official

Name: AMANDA MELISSA MOFFITT
Title or Position: ADMINISTRATIVE SUPERVISOR I
Credential:
Phone: 909-777-0726