=====================================================
General NPI Number Information
=====================================================
NPI Number | 1801761358
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | SAN GORGONIO MEMORIAL HEALTH CARE DISTRICT
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 10/06/2025
-----------------------------------------------------
Last Update Date | 10/06/2025
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 264 N HIGHLAND SPRINGS AVE STE 3D
-----------------------------------------------------
City | BANNING
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 92220-3085
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 951-951-2762
-----------------------------------------------------
Fax | 951-848-7985
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 264 N HIGHLAND SPRINGS AVE STE 3D
-----------------------------------------------------
City | BANNING
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 92220-3085
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 951-951-2762
-----------------------------------------------------
Fax | 951-848-7985
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | EXEUTIVE
-----------------------------------------------------
Name | ANGELA BRADY
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 951-769-2121
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 207Q00000X
-----------------------------------------------------
Taxonomy Name | Family Medicine Physician
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------