Basic Information
| Provider Information | |||||||||
| NPI: | 1578823647 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | INLAND BEHAVIORAL AND HEALTH SERVICES, INC. | ||||||||
| LastName: | |||||||||
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| OtherOrganizationName: | INLAND BEHAVIORAL AND HEALTH SERVICES, INC. | ||||||||
| OtherOrganizationType: | 5 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1963 N E ST | ||||||||
| Address2: | |||||||||
| City: | SAN BERNARDINO | ||||||||
| State: | CA | ||||||||
| PostalCode: | 924053919 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9098816146 | ||||||||
| FaxNumber: | 9098813479 | ||||||||
| Practice Location | |||||||||
| Address1: | 1070 E. RAMSEY STEET | ||||||||
| Address2: | |||||||||
| City: | BANNING | ||||||||
| State: | CA | ||||||||
| PostalCode: | 922200998 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9518462560 | ||||||||
| FaxNumber: | 9518492310 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/23/2012 | ||||||||
| LastUpdateDate: | 07/19/2017 | ||||||||
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| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | LINDSEY | ||||||||
| AuthorizedOfficialFirstName: | TEMETRY | ||||||||
| AuthorizedOfficialMiddleName: | A. | ||||||||
| AuthorizedOfficialTitleorPosition: | CEO/PRESIDENT | ||||||||
| AuthorizedOfficialTelephone: | 9097088158 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | Y | ||||||||
| ParentOrganizationLBN: | INLAND BEHAVIORAL AND HEALTH SERVICES, INC. | ||||||||
| AuthorizedOfficialNamePrefix: | DR. | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 261QF0400X | Y | Ambulatory Health Care Facilities | Clinic/Center | Federally Qualified Health Center (FQHC) |
ID Information
| ID | Type | State | Issuer | Description | FHC 70520F | 05 | CA | MEDICAID |