=====================================================
General NPI Number Information
=====================================================
NPI Number | 1134621923
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | RIVERSIDE-SAN BERNARDINO COUNTY INDIAN HEALTH, INC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 03/07/2018
-----------------------------------------------------
Last Update Date | 08/25/2021
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 170 YUCCA AVE
-----------------------------------------------------
City | BARSTOW
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 92311-3231
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 760-256-9016
-----------------------------------------------------
Fax | 760-256-7856
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 11980 MOUNT VERNON AVE
-----------------------------------------------------
City | GRAND TERRACE
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 92313-5172
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 909-864-1097
-----------------------------------------------------
Fax | 951-225-6879
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | CEO
-----------------------------------------------------
Name | WILLIAM THOMSEN
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 909-864-1097
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 261QF0400X
-----------------------------------------------------
Taxonomy Name | Federally Qualified Health Center (FQHC)
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------