Basic Information
Provider Information | |||||||||
NPI: | 1427385558 | ||||||||
EntityType: | 2 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: | COUNTY OF SAN BERNARDINO | ||||||||
LastName: |   | ||||||||
FirstName: |   | ||||||||
MiddleName: |   | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: |   | ||||||||
OtherOrganizationName: | MCKEE INTEGRATED HEALTH CENTER | ||||||||
OtherOrganizationType: | 3 | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 303 E VANDERBILT WAY | ||||||||
Address2: |   | ||||||||
City: | SAN BERNARDINO | ||||||||
State: | CA | ||||||||
PostalCode: | 924150026 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 9093880801 | ||||||||
FaxNumber: | 9098900435 | ||||||||
Practice Location | |||||||||
Address1: | 2372 STERLING AVE | ||||||||
Address2: |   | ||||||||
City: | SAN BERNARDINO | ||||||||
State: | CA | ||||||||
PostalCode: | 924044624 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 9094228029 | ||||||||
FaxNumber: |   | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 11/10/2009 | ||||||||
LastUpdateDate: | 11/12/2014 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: |   | ||||||||
AuthorizedOfficialLastName: | THOMAS | ||||||||
AuthorizedOfficialFirstName: | CASONYA | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: | DIRECTOR | ||||||||
AuthorizedOfficialTelephone: | 9093880801 | ||||||||
IsSoleProprietor: |   | ||||||||
IsOrganizationSubpart: | Y | ||||||||
ParentOrganizationLBN: | DEPARTMENT OF BEHAVIORAL HEALTH | ||||||||
AuthorizedOfficialNamePrefix: | MS. | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 261QM0801X | N/A | CA | Y |   | Ambulatory Health Care Facilities | Clinic/Center | Mental Health (Including Community Mental Health Center) |
ID Information
ID | Type | State | Issuer | Description | PENDING | 05 | CA |   | MEDICAID |