Basic Information
| Provider Information | |||||||||
| NPI: | 1467692392 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | COMMUNITY HEALTH SYSTEMS, INC. | ||||||||
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| OtherOrganizationName: | FALLBROOK WOMEN'S CLINIC | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 22675 ALESSANDRO BLVD | ||||||||
| Address2: | |||||||||
| City: | MORENO VALLEY | ||||||||
| State: | CA | ||||||||
| PostalCode: | 925538551 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9515712300 | ||||||||
| FaxNumber: | 9515712330 | ||||||||
| Practice Location | |||||||||
| Address1: | 1328 S MISSION RD | ||||||||
| Address2: | |||||||||
| City: | FALLBROOK | ||||||||
| State: | CA | ||||||||
| PostalCode: | 920284006 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7604514730 | ||||||||
| FaxNumber: | 7604514700 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 03/05/2009 | ||||||||
| LastUpdateDate: | 05/10/2011 | ||||||||
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| AuthorizedOfficialLastName: | JOHNS | ||||||||
| AuthorizedOfficialFirstName: | JACK | ||||||||
| AuthorizedOfficialMiddleName: | E | ||||||||
| AuthorizedOfficialTitleorPosition: | CHIEF EXECUTIVE OFFICER | ||||||||
| AuthorizedOfficialTelephone: | 9515712300 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | Y | ||||||||
| ParentOrganizationLBN: | COMMUNITY HEALTH SYSTEMS, INC. | ||||||||
| AuthorizedOfficialNamePrefix: | MR. | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207V00000X | 080000150 | CA | Y | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Obstetrics & Gynecology |
ID Information
| ID | Type | State | Issuer | Description | 1982756086 | 05 | CA | MEDICAID | BCP70275G | 05 | CA | MEDICAID | EAP70324F | 05 | CA | MEDICAID | HAP70275G | 05 | CA | MEDICAID | 4998231 | 05 | CA | MEDICAID |