Basic Information
Provider Information | |||||||||
NPI: | 1407921877 | ||||||||
EntityType: | 2 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: | COUNTY OF RIVERSIDE | ||||||||
LastName: |   | ||||||||
FirstName: |   | ||||||||
MiddleName: |   | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: |   | ||||||||
OtherOrganizationName: | SAN JACINTO MENTAL HEALTH | ||||||||
OtherOrganizationType: | 3 | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | PO BOX 7549 | ||||||||
Address2: |   | ||||||||
City: | RIVERSIDE | ||||||||
State: | CA | ||||||||
PostalCode: | 925137549 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 9513586900 | ||||||||
FaxNumber: | 9513586905 | ||||||||
Practice Location | |||||||||
Address1: | 950 N RAMONA BLVD | ||||||||
Address2: | SUITES 1-3 | ||||||||
City: | SAN JACINTO | ||||||||
State: | CA | ||||||||
PostalCode: | 925822567 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 9514872674 | ||||||||
FaxNumber: | 9514872679 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 11/21/2006 | ||||||||
LastUpdateDate: | 09/09/2022 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: |   | ||||||||
AuthorizedOfficialLastName: | CHANG | ||||||||
AuthorizedOfficialFirstName: | MATTHEW | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: | DIRECTOR RUHS - BEHAVIORAL HEALTH | ||||||||
AuthorizedOfficialTelephone: | 9513584501 | ||||||||
IsSoleProprietor: |   | ||||||||
IsOrganizationSubpart: | N | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: | DR. | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: | 09/09/2022 |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 251S00000X |   |   | Y |   | Agencies | Community/Behavioral Health |   |
ID Information
ID | Type | State | Issuer | Description | 33CS | 05 | CA |   | MEDICAID |