Basic Information
| Provider Information | |||||||||
| NPI: | 1427464429 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | INLAND VALLEY RECOVERY SERVICES | ||||||||
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| OtherOrganizationName: | SAN BERNARDINO RECOVERY CENTER | ||||||||
| OtherOrganizationType: | 5 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 916 N MOUNTAIN AVE | ||||||||
| Address2: | SUITE A | ||||||||
| City: | UPLAND | ||||||||
| State: | CA | ||||||||
| PostalCode: | 917863697 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9099321069 | ||||||||
| FaxNumber: | 9099321087 | ||||||||
| Practice Location | |||||||||
| Address1: | 955 N D ST | ||||||||
| Address2: | |||||||||
| City: | SAN BERNARDINO | ||||||||
| State: | CA | ||||||||
| PostalCode: | 924103519 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9098896519 | ||||||||
| FaxNumber: | 9098896560 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/10/2014 | ||||||||
| LastUpdateDate: | 07/10/2014 | ||||||||
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| AuthorizedOfficialLastName: | BLACKSTONE | ||||||||
| AuthorizedOfficialFirstName: | STACY | ||||||||
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| AuthorizedOfficialTitleorPosition: | CEO | ||||||||
| AuthorizedOfficialTelephone: | 9099321069 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 251S00000X | 360001ABN | CA | Y | Agencies | Community/Behavioral Health |
No ID Information.