Healthcare Provider Details

I. General information

NPI: 1396726378
Provider Name (Legal Business Name): COUNTY OF RIVERSIDE-COMMUNITY HEALTH AGENCY
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/08/2005
Last Update Date: 09/11/2025
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2499 E LAKESHORE DR
LAKE ELSINORE CA
92530-4446
US

IV. Provider business mailing address

PO BOX 7849
RIVERSIDE CA
92513-7849
US

V. Phone/Fax

Practice location:
  • Phone: 951-674-3250
  • Fax: 951-245-4502
Mailing address:
  • Phone: 951-358-5222
  • Fax: 951-358-5235

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License NumberA67273
License Number StateCA
# 2
Primary TaxonomyN
Taxonomy Code261QF0400X
TaxonomyFederally Qualified Health Center (FQHC)
License Number207Q00000X
License Number StateCA

VIII. Authorized Official

Name: MR. MICHAEL TWEEDELL
Title or Position: DEPUTY DIRECTOR
Credential: M.P.H
Phone: 951-358-5222