Basic Information
| Provider Information | |||||||||
| NPI: | 1508373119 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | MONTCLAIR COMMUNITY HEALTH CENTER | ||||||||
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| Mailing Information | |||||||||
| Address1: | 5050 SAN BERNARDINO ST | ||||||||
| Address2: | |||||||||
| City: | MONTCLAIR | ||||||||
| State: | CA | ||||||||
| PostalCode: | 917632326 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9092815800 | ||||||||
| FaxNumber: | 9092815858 | ||||||||
| Practice Location | |||||||||
| Address1: | 5050 SAN BERNARDINO ST | ||||||||
| Address2: | |||||||||
| City: | MONTCLAIR | ||||||||
| State: | CA | ||||||||
| PostalCode: | 917632326 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9092815800 | ||||||||
| FaxNumber: | 9092815858 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 01/04/2018 | ||||||||
| LastUpdateDate: | 01/04/2018 | ||||||||
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| AuthorizedOfficialLastName: | LALLY | ||||||||
| AuthorizedOfficialFirstName: | JAMES | ||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | PRESIDENT | ||||||||
| AuthorizedOfficialTelephone: | 9092815800 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | Y | ||||||||
| ParentOrganizationLBN: | HEALTH SERVICE ALLIANCE | ||||||||
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| AuthorizedOfficialCredential: | DO | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 103T00000X | N | 193200000X MULTI-SPECIALTY GROUP | Behavioral Health & Social Service Providers | Psychologist | 207Q00000X | Y | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Family Medicine |
ID Information
| ID | Type | State | Issuer | Description | 1407306772 | 05 | CA | MEDICAID |