Healthcare Provider Details

I. General information

NPI: 1922686955
Provider Name (Legal Business Name): RIVERSIDE/SAN BERNARDINO COUNTY INDIAN HEALTH, INC.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/31/2021
Last Update Date: 03/31/2021
Certification Date: 03/09/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

65175 STATE HIGHWAY 74
MOUNTAIN CENTER CA
92561
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:
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: MARK JENSEN
Title or Position: CFO
Credential:
Phone: 909-864-1097