Basic Information
| Provider Information | |||||||||
| NPI: | 1285709139 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | COUNTY OF RIVERSIDE | ||||||||
| LastName: | |||||||||
| FirstName: | |||||||||
| MiddleName: | |||||||||
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| OtherOrganizationName: | ADULT SYSTEMS OF CARE (HOMELESS PROGRAMS) | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 7549 | ||||||||
| Address2: | |||||||||
| City: | RIVERSIDE | ||||||||
| State: | CA | ||||||||
| PostalCode: | 925137549 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9513586900 | ||||||||
| FaxNumber: | 9513586905 | ||||||||
| Practice Location | |||||||||
| Address1: | 1827 ATLANTA AVE | ||||||||
| Address2: | SUITE D3 | ||||||||
| City: | RIVERSIDE | ||||||||
| State: | CA | ||||||||
| PostalCode: | 925077419 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9519558000 | ||||||||
| FaxNumber: | 9519558010 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 11/22/2006 | ||||||||
| LastUpdateDate: | 08/22/2020 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
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| AuthorizedOfficialLastName: | WENGERD | ||||||||
| AuthorizedOfficialFirstName: | JERRY | ||||||||
| AuthorizedOfficialMiddleName: | A | ||||||||
| AuthorizedOfficialTitleorPosition: | DIRECTOR, DEPT. OF MENTAL HEALTH | ||||||||
| AuthorizedOfficialTelephone: | 9513584501 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | MR. | ||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 251S00000X | Y | Agencies | Community/Behavioral Health |
ID Information
| ID | Type | State | Issuer | Description | 33EZ | 05 | CA | MEDICAID |