Healthcare Provider Details

I. General information

NPI: 1427247386
Provider Name (Legal Business Name): SAN BERNARDINO COUNTY/CCS
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/17/2007
Last Update Date: 10/27/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1451 E. PENNSYLVANIA AVE. REDLANDS MTU
REDLANDS CA
92374
US

IV. Provider business mailing address

351 N MOUNTAIN VIEW AVE
SAN BERNARDINO CA
92415-1018
US

V. Phone/Fax

Practice location:
  • Phone: 909-307-2441
  • Fax:
Mailing address:
  • Phone: 909-387-6218
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code224Z00000X
TaxonomyOccupational Therapy Assistant
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code2251P0200X
TaxonomyPediatric Physical Therapist
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code225200000X
TaxonomyPhysical Therapy Assistant
License Number
License Number State
# 4
Primary TaxonomyY
Taxonomy Code225XP0200X
TaxonomyPediatric Occupational Therapist
License Number
License Number State

VIII. Authorized Official

Name: MR. KEN ADAMS
Title or Position: PROGRAM MANAGER
Credential: MPH
Phone: 909-387-8400