MEDICARE: SAN BERNARDINO MOUNTAINS COMMUNITY HOSPITAL DISTRICT

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	275N00000X	Medicare Defined Swing Bed Hospital Unit	HSP30260I	CA

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1073663662
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	SAN BERNARDINO MOUNTAINS COMMUNITY HOSPITAL DISTRICT

Provider Business Mailing Address
First Line	:	PO BOX 70
Second Line	:
City	:	LAKE ARROWHEAD
State	:	CA
Zip	:	92352-0070
Country	:	US
Telephone Number	:	909-336-3651
Fax Number	:	909-336-1179

Provider Business Practice Location Address
First Line	:	29101 HOSPITAL RD
Second Line	:
City	:	LAKE ARROWHEAD
State	:	CA
Zip	:	92352-0070
Country	:	US
Telephone Number	:	909-336-3651
Fax Number	:	909-336-1179

Authorized Official
Title or Position	:	CFO
Name	:	MS. YVONNE D WAGGENER
Credential	:
Telephone Number	:	909-336-3651

Provider Enumeration Date	:	01/12/2007
Last Update Date	:	08/25/2023

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