Basic Information
| Provider Information | |||||||||
| NPI: | 1245380799 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | SAN BERNARDINO MOUNTAINS COMMUNITY HOSPITAL DISTRICT | ||||||||
| LastName: | |||||||||
| FirstName: | |||||||||
| MiddleName: | |||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | |||||||||
| OtherOrganizationName: | MOUNTAINS COMMUNITY HOSPITAL | ||||||||
| OtherOrganizationType: | 3 | ||||||||
| OtherLastName: | |||||||||
| OtherFirstName: | |||||||||
| OtherMiddleName: | |||||||||
| OtherNamePrefix: | |||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | |||||||||
| OtherLastNameType: | |||||||||
| Mailing Information | |||||||||
| Address1: | PO BOX 70 | ||||||||
| Address2: | |||||||||
| City: | LAKE ARROWHEAD | ||||||||
| State: | CA | ||||||||
| PostalCode: | 923520070 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9093363651 | ||||||||
| FaxNumber: | 9093361179 | ||||||||
| Practice Location | |||||||||
| Address1: | 29101 HOSPITAL RD | ||||||||
| Address2: | |||||||||
| City: | LAKE ARROWHEAD | ||||||||
| State: | CA | ||||||||
| PostalCode: | 923520070 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9093363651 | ||||||||
| FaxNumber: | 9093361179 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 01/10/2007 | ||||||||
| LastUpdateDate: | 11/15/2016 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
| NPIDeactivationDate: | |||||||||
| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | HARRISON | ||||||||
| AuthorizedOfficialFirstName: | CHARLES | ||||||||
| AuthorizedOfficialMiddleName: | H. | ||||||||
| AuthorizedOfficialTitleorPosition: | CEO | ||||||||
| AuthorizedOfficialTelephone: | 9093363651 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | MR. | ||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 282NC0060X | CGP160427 | CA | N | Hospitals | General Acute Care Hospital | Critical Access | 282NC0060X | HSP40260I | CA | N | Hospitals | General Acute Care Hospital | Critical Access | 282NC0060X | CGP171049 | CA | N | Hospitals | General Acute Care Hospital | Critical Access | 282NC0060X | PHB366420 | CA | N | Hospitals | General Acute Care Hospital | Critical Access | 282NC0060X | HSP30260I | CA | Y | Hospitals | General Acute Care Hospital | Critical Access |
ID Information
| ID | Type | State | Issuer | Description | CGP171049 | 05 | CA | MEDICAID | HSP30260I | 05 | CA | MEDICAID | PHB366420 | 05 | CA | MEDICAID | CGP160427 | 05 | CA | MEDICAID | HSP40260I | 05 | CA | MEDICAID |