Basic Information
Provider Information | |||||||||
NPI: | 1124237425 | ||||||||
EntityType: | 2 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: | DEPARTMENT OF BEHAVIORAL HEALTH, SAN BERNARDINO COUNTY CA | ||||||||
LastName: |   | ||||||||
FirstName: |   | ||||||||
MiddleName: |   | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: |   | ||||||||
OtherOrganizationName: | VICTORVILLE MULTIDIAGNOSIS CLINIC | ||||||||
OtherOrganizationType: | 3 | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 268 W HOSPITALITY LN | ||||||||
Address2: | SUITE 400 | ||||||||
City: | SAN BERNARDINO | ||||||||
State: | CA | ||||||||
PostalCode: | 924150001 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 9093823080 | ||||||||
FaxNumber: | 9093823105 | ||||||||
Practice Location | |||||||||
Address1: | 12625 HESPERIA RD | ||||||||
Address2: |   | ||||||||
City: | VICTORVILLE | ||||||||
State: | CA | ||||||||
PostalCode: | 923957720 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 9093823080 | ||||||||
FaxNumber: | 9093823105 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 05/22/2007 | ||||||||
LastUpdateDate: | 08/22/2020 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: |   | ||||||||
AuthorizedOfficialLastName: | DAY | ||||||||
AuthorizedOfficialFirstName: | MICHAEL | ||||||||
AuthorizedOfficialMiddleName: | J. | ||||||||
AuthorizedOfficialTitleorPosition: | INFORMATION TECHNOLOGY MANAGER | ||||||||
AuthorizedOfficialTelephone: | 9093880570 | ||||||||
IsSoleProprietor: |   | ||||||||
IsOrganizationSubpart: | N | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: | MR. | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 261QM1300X | ZZZ74743Z | CA | Y |   | Ambulatory Health Care Facilities | Clinic/Center | Multi-Specialty |
ID Information
ID | Type | State | Issuer | Description | 36AC | 01 | CA | MEDI-CAL PROVIDER NUMBER | OTHER |