Basic Information
Provider Information | |||||||||
NPI: | 1275941049 | ||||||||
EntityType: | 2 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: | FAMILY SERVICE AGENCY OF SAN BERNARDINO | ||||||||
LastName: |   | ||||||||
FirstName: |   | ||||||||
MiddleName: |   | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: |   | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 1669 N E ST | ||||||||
Address2: |   | ||||||||
City: | SAN BERNARDINO | ||||||||
State: | CA | ||||||||
PostalCode: | 924054405 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 9098866737 | ||||||||
FaxNumber: | 9098813871 | ||||||||
Practice Location | |||||||||
Address1: | 109 1/2 N 7TH AVE | ||||||||
Address2: |   | ||||||||
City: | BARSTOW | ||||||||
State: | CA | ||||||||
PostalCode: | 923112337 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 7602569326 | ||||||||
FaxNumber: | 7602569326 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 07/24/2014 | ||||||||
LastUpdateDate: | 10/02/2014 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: |   | ||||||||
AuthorizedOfficialLastName: | CORMICAN | ||||||||
AuthorizedOfficialFirstName: | PATRICE | ||||||||
AuthorizedOfficialMiddleName: | J | ||||||||
AuthorizedOfficialTitleorPosition: | CEO | ||||||||
AuthorizedOfficialTelephone: | 9098866737 | ||||||||
IsSoleProprietor: |   | ||||||||
IsOrganizationSubpart: | N | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: | MS. | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 251S00000X |   |   | Y |   | Agencies | Community/Behavioral Health |   |
No ID Information.