Basic Information
| Provider Information | |||||||||
| NPI: | 1285700435 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | COUNTY OF RIVERSIDE | ||||||||
| LastName: | |||||||||
| FirstName: | |||||||||
| MiddleName: | |||||||||
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| Credential: | |||||||||
| OtherOrganizationName: | BLYTHE SUBSTANCE USE PROGRAM | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 3525 PRESLEY AVE | ||||||||
| Address2: | |||||||||
| City: | RIVERSIDE | ||||||||
| State: | CA | ||||||||
| PostalCode: | 925074453 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9517822400 | ||||||||
| FaxNumber: | 9516834904 | ||||||||
| Practice Location | |||||||||
| Address1: | 1297 W HOBSONWAY | ||||||||
| Address2: | |||||||||
| City: | BLYTHE | ||||||||
| State: | CA | ||||||||
| PostalCode: | 922251423 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7609215019 | ||||||||
| FaxNumber: | 7609215010 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 11/28/2006 | ||||||||
| LastUpdateDate: | 12/10/2014 | ||||||||
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| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | WENGERD | ||||||||
| AuthorizedOfficialFirstName: | JERRY | ||||||||
| AuthorizedOfficialMiddleName: | A | ||||||||
| AuthorizedOfficialTitleorPosition: | DIRECTOR, DEPT. OF MENTAL HEALTH | ||||||||
| AuthorizedOfficialTelephone: | 9513584501 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | MR. | ||||||||
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| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 251S00000X | Y | Agencies | Community/Behavioral Health |
ID Information
| ID | Type | State | Issuer | Description | 333365 | 01 | CA | CADDS | OTHER | 3365 | 05 | CA | MEDICAID |