MEDICARE: FOUNDATION FOR CALIFORNIA STATE UNIVERSITY SAN BERNARDINO

Medicare Provider Information

Scope of Practice

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

#	Taxonomy Code	Taxonomy
1	251B00000X	Case Management Agency
2	252Y00000X	Early Intervention Provider Agency
3	251S00000X	Community/Behavioral Health Agency

General Provider Information

NPI Number	:	1225213697
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	FOUNDATION FOR CALIFORNIA STATE UNIVERSITY SAN BERNARDINO

Provider Business Mailing Address
First Line	:	5500 UNIVERSITY PKWY
Second Line	:
City	:	SAN BERNARDINO
State	:	CA
Zip	:	92407-2318
Country	:	US
Telephone Number	:	909-537-3939
Fax Number	:

Provider Business Practice Location Address
First Line	:	165 W HOSPITALITY LN
Second Line	:	SUITE 12
City	:	SAN BERNARDINO
State	:	CA
Zip	:	92408-3334
Country	:	US
Telephone Number	:	909-891-1880
Fax Number	:	909-891-1888

Authorized Official
Title or Position	:	GENERAL MANAGER
Name	:	MS. DEBORAH BURNS
Credential	:
Telephone Number	:	909-537-3939

Provider Enumeration Date	:	01/04/2008
Last Update Date	:	01/04/2008

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