Healthcare Provider Details

I. General information

NPI: 1720105059
Provider Name (Legal Business Name): RIVERSIDE COUNTY DEPARTMENT OF MENTAL HEALTH
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/23/2007
Last Update Date: 08/22/2020
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4095 COUNTY CIRCLE DR
RIVERSIDE CA
92503-3410
US

IV. Provider business mailing address

4095 COUNTY CIRCLE DR
RIVERSIDE CA
92503-3410
US

V. Phone/Fax

Practice location:
  • Phone: 951-358-4501
  • Fax: 951-358-4513
Mailing address:
  • Phone: 951-358-4501
  • Fax: 951-358-4513

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261Q00000X
TaxonomyClinic/Center
License NumberLCS6297
License Number StateCA

VIII. Authorized Official

Name: MR. JERRY ALLEN WENGERD
Title or Position: DIRECTOR
Credential: MSW
Phone: 951-358-4501