Basic Information
| Provider Information | |||||||||
| NPI: | 1013272558 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | COUNTY OF SAN BERNARDINO | ||||||||
| LastName: | |||||||||
| FirstName: | |||||||||
| MiddleName: | |||||||||
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| OtherOrganizationName: | FONTANA CHOICE SUBSTANCE USE DISORDER TREATMENT | ||||||||
| OtherOrganizationType: | 3 | ||||||||
| OtherLastName: | |||||||||
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| Mailing Information | |||||||||
| Address1: | 303 E VANDERBILT WAY | ||||||||
| Address2: | |||||||||
| City: | SAN BERNARDINO | ||||||||
| State: | CA | ||||||||
| PostalCode: | 924150026 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9093880900 | ||||||||
| FaxNumber: | 9098900435 | ||||||||
| Practice Location | |||||||||
| Address1: | 17830 ARROW BLVD | ||||||||
| Address2: | |||||||||
| City: | FONTANA | ||||||||
| State: | CA | ||||||||
| PostalCode: | 92335 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9093566439 | ||||||||
| FaxNumber: | 9098900435 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/11/2012 | ||||||||
| LastUpdateDate: | 06/17/2021 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
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| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | OCHOA | ||||||||
| AuthorizedOfficialFirstName: | ERICA | ||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | CHIEF COMPLIANCE OFFICER | ||||||||
| AuthorizedOfficialTelephone: | 9093880882 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | Y | ||||||||
| ParentOrganizationLBN: | COUNTY OF SAN BERNARDINO | ||||||||
| AuthorizedOfficialNamePrefix: | |||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | 06/17/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 261QR0405X | Y | Ambulatory Health Care Facilities | Clinic/Center | Rehabilitation, Substance Use Disorder |
No ID Information.