Healthcare Provider Details

I. General information

NPI: 1619377942
Provider Name (Legal Business Name): DHEW IND HLTH SV HLTH SVS & MNTL HLTH ADM
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/22/2014
Last Update Date: 05/26/2021
Certification Date: 05/26/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

9010 MAGNOLIA AVE
RIVERSIDE CA
92503-4431
US

IV. Provider business mailing address

PO BOX 95460
CLEVELAND OH
44101-0033
US

V. Phone/Fax

Practice location:
  • Phone: 951-509-8914
  • Fax: 602-200-5383
Mailing address:
  • Phone: 602-581-6088
  • Fax: 602-263-1619

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QS1000X
TaxonomyStudent Health Clinic/Center
License Number
License Number State

VIII. Authorized Official

Name: LAURA A TILLMAN
Title or Position: CMO
Credential: MD
Phone: 602-263-1674