Healthcare Provider Details

I. General information

NPI: 1679200976
Provider Name (Legal Business Name): RIVERSIDE SAN BERNARDINO COUNTY INDIAN HEALTH INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/05/2022
Last Update Date: 08/05/2022
Certification Date: 07/27/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

66655 MARTINEZ RD
THERMAL CA
92274-9007
US

IV. Provider business mailing address

11980 MOUNT VERNON AVE
GRAND TERRACE CA
92313-5172
US

V. Phone/Fax

Practice location:
  • Phone: 760-397-4476
  • Fax: 951-225-6879
Mailing address:
  • Phone: 909-864-1097
  • Fax: 951-225-6879

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code333600000X
TaxonomyPharmacy
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code332800000X
TaxonomyIndian Health Service/Tribal/Urban Indian Health (I/T/U) Pharmacy
License Number
License Number State

VIII. Authorized Official

Name: WILLIAM THOMSEN
Title or Position: CEO
Credential:
Phone: 909-864-1097