Basic Information
| Provider Information | |||||||||
| NPI: | 1245680735 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | FAMILY SERVICE AGENCY OF SAN BERNARDINO | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1669 N E ST | ||||||||
| Address2: | |||||||||
| City: | SAN BERNARDINO | ||||||||
| State: | CA | ||||||||
| PostalCode: | 924054405 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9098866737 | ||||||||
| FaxNumber: | 9098813871 | ||||||||
| Practice Location | |||||||||
| Address1: | 11424 CHAMBERLAINE WAY | ||||||||
| Address2: | SUITE 11-12 | ||||||||
| City: | ADELANTO | ||||||||
| State: | CA | ||||||||
| PostalCode: | 923012869 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9098866737 | ||||||||
| FaxNumber: | 9098813871 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/15/2016 | ||||||||
| LastUpdateDate: | 06/15/2016 | ||||||||
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| AuthorizedOfficialLastName: | CORMICAN | ||||||||
| AuthorizedOfficialFirstName: | PATRICE | ||||||||
| AuthorizedOfficialMiddleName: | J | ||||||||
| AuthorizedOfficialTitleorPosition: | CEO | ||||||||
| AuthorizedOfficialTelephone: | 9098866737 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | Y | ||||||||
| ParentOrganizationLBN: | FAMILY SERVICE AGENCY OF SAN BERNARDINO | ||||||||
| AuthorizedOfficialNamePrefix: | MS. | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 251S00000X | Y | Agencies | Community/Behavioral Health |
No ID Information.