Basic Information
| Provider Information | |||||||||
| NPI: | 1669524534 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | COMMUNITY HEALTH SYSTEMS INC | ||||||||
| LastName: | |||||||||
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| OtherOrganizationName: | EASTSIDE COMMUNITY HEALTH 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: | 1744 UNIVERSITY AVE | ||||||||
| Address2: | |||||||||
| City: | RIVERSIDE | ||||||||
| State: | CA | ||||||||
| PostalCode: | 925075364 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9512248220 | ||||||||
| FaxNumber: | 9512248230 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 01/18/2007 | ||||||||
| LastUpdateDate: | 09/02/2011 | ||||||||
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| AuthorizedOfficialLastName: | JOHNS | ||||||||
| AuthorizedOfficialFirstName: | JACK | ||||||||
| AuthorizedOfficialMiddleName: | E | ||||||||
| AuthorizedOfficialTitleorPosition: | CHIEF EXECUTIVE OFFICER | ||||||||
| AuthorizedOfficialTelephone: | 9515712300 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 122300000X | 47987 | CA | N | 193200000X MULTI-SPECIALTY GROUP | Dental Providers | Dentist | 122300000X | 40093 | CA | N | 193200000X MULTI-SPECIALTY GROUP | Dental Providers | Dentist | 122300000X | 27343 | CA | N | 193200000X MULTI-SPECIALTY GROUP | Dental Providers | Dentist | 122300000X | 58321 | CA | N | 193200000X MULTI-SPECIALTY GROUP | Dental Providers | Dentist | 1223G0001X | 40996 | CA | N | 193200000X MULTI-SPECIALTY GROUP | Dental Providers | Dentist | General Practice | 1223G0001X | 40734 | CA | N | 193200000X MULTI-SPECIALTY GROUP | Dental Providers | Dentist | General Practice | 1223P0221X | 46894 | CA | N | 193200000X MULTI-SPECIALTY GROUP | Dental Providers | Dentist | Pediatric Dentistry | 207Q00000X | A50693 | CA | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Family Medicine | 207Q00000X | A86874 | CA | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Family Medicine | 207Q00000X | 11901 | CA | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Family Medicine | 207Q00000X | 15571 | CA | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Family Medicine | 207Q00000X | 11428 | CA | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Family Medicine | 261QF0400X | 250000756 | CA | Y | Ambulatory Health Care Facilities | Clinic/Center | Federally Qualified Health Center (FQHC) |
ID Information
| ID | Type | State | Issuer | Description | 1669524534 | 05 | CA | MEDICAID | EAP70324F | 05 | CA | MEDICAID |