Basic Information
Provider Information | |||||||||
NPI: | 1639527062 | ||||||||
EntityType: | 2 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: | HOMELESS OUTREACH SUPPORT TEAM | ||||||||
LastName: |   | ||||||||
FirstName: |   | ||||||||
MiddleName: |   | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: |   | ||||||||
OtherOrganizationName: | SAN BERNARDINO COUNTY | ||||||||
OtherOrganizationType: | 5 | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 850 E FOOTHILL BLVD | ||||||||
Address2: |   | ||||||||
City: | RIALTO | ||||||||
State: | CA | ||||||||
PostalCode: | 923765230 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 9094214633 | ||||||||
FaxNumber: |   | ||||||||
Practice Location | |||||||||
Address1: | 850 E FOOTHILL BLVD | ||||||||
Address2: |   | ||||||||
City: | RIALTO | ||||||||
State: | CA | ||||||||
PostalCode: | 923765230 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 9094214633 | ||||||||
FaxNumber: |   | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 05/26/2016 | ||||||||
LastUpdateDate: | 05/26/2016 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: |   | ||||||||
AuthorizedOfficialLastName: | SWEITZER | ||||||||
AuthorizedOfficialFirstName: | MICHAEL | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: | PROGRAM MANAGER I | ||||||||
AuthorizedOfficialTelephone: | 9094219419 | ||||||||
IsSoleProprietor: |   | ||||||||
IsOrganizationSubpart: | N | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: | MR. | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 171M00000X |   |   | Y | 193200000X MULTI-SPECIALTY GROUP | Other Service Providers | Case Manager/Care Coordinator |   |
No ID Information.