Healthcare Provider Details

I. General information

NPI: 1508157520
Provider Name (Legal Business Name): BLOOD BANK OF SAN BERNARDINO AND RIVERSIDE COUNTIES
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/25/2011
Last Update Date: 04/25/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

384 W ORANGE SHOW RD
SAN BERNARDINO CA
92408-2028
US

IV. Provider business mailing address

PO BOX 5729
SAN BERNARDINO CA
92412-5729
US

V. Phone/Fax

Practice location:
  • Phone: 909-885-6503
  • Fax: 909-381-2036
Mailing address:
  • Phone: 909-885-6503
  • Fax: 909-381-2036

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code291U00000X
TaxonomyClinical Medical Laboratory
License NumberCLF3556
License Number StateCA
# 2
Primary TaxonomyY
Taxonomy Code331L00000X
TaxonomyBlood Bank
License Number9021
License Number StateCA

VIII. Authorized Official

Name: DR. FREDERICK B AXELROD
Title or Position: PRESIDENT/CEO/MEDICAL DIRECTOR
Credential: M.D. , MBA
Phone: 909-885-6503