Healthcare Provider Details

I. General information

NPI: 1366028086
Provider Name (Legal Business Name): RIVERSIDE-SAN BERNARDINO COUNTY INDIAN HEALTH, INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/23/2021
Last Update Date: 09/16/2021
Certification Date: 09/16/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

65175 ST. HIGHWAY 74
MOUNTAIN CENTER CA
92561-9231
US

IV. Provider business mailing address

11980 MOUNT VERNON AVE
GRAND TERRACE CA
92313-5172
US

V. Phone/Fax

Practice location:
  • Phone: 951-823-8882
  • Fax: 951-225-6879
Mailing address:
  • Phone: 909-864-1097
  • Fax: 951-225-6879

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QF0400X
TaxonomyFederally Qualified Health Center (FQHC)
License Number
License Number State

VIII. Authorized Official

Name: WILLIAM THOMSEN
Title or Position: CEO
Credential:
Phone: 909-864-1097