MEDICARE: MT. VERNON COMMUNITY HEALTH CENTER

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	261QP2300X	Primary Care Clinic/Center		CA
2	261QC1500X	Community Health Clinic/Center		CA

General Provider Information

NPI Number	:	1144517863
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	MT. VERNON COMMUNITY HEALTH CENTER

Provider Business Mailing Address
First Line	:	1655 N MOUNT VERNON AVE
Second Line	:	SUITE C
City	:	SAN BERNARDINO
State	:	CA
Zip	:	92411-1427
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	1655 N MOUNT VERNON AVE
Second Line	:	SUITE C
City	:	SAN BERNARDINO
State	:	CA
Zip	:	92411-1427
Country	:	US
Telephone Number	:	909-586-6271
Fax Number	:	888-777-0807

Authorized Official
Title or Position	:	PRESIDENT/CEO
Name	:	RUZAN GEVORKYAN
Credential	:
Telephone Number	:	909-586-6271

Provider Enumeration Date	:	07/01/2011
Last Update Date	:	07/01/2011

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