Basic Information
| Provider Information | |||||||||
| NPI: | 1669681961 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | WEST VALLEY FAST | ||||||||
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| Mailing Information | |||||||||
| Address1: | 268 W HOSPITALITY LN | ||||||||
| Address2: | SUITE 400 | ||||||||
| City: | SAN BERNARDINO | ||||||||
| State: | CA | ||||||||
| PostalCode: | 924150001 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9093823080 | ||||||||
| FaxNumber: | 9093823105 | ||||||||
| Practice Location | |||||||||
| Address1: | 9478 ETIWANDA AVE | ||||||||
| Address2: | |||||||||
| City: | RANCHO CUCAMONGA | ||||||||
| State: | CA | ||||||||
| PostalCode: | 917399662 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9093823080 | ||||||||
| FaxNumber: | 9093823105 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/22/2007 | ||||||||
| LastUpdateDate: | 07/13/2007 | ||||||||
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| AuthorizedOfficialLastName: | DAY | ||||||||
| AuthorizedOfficialFirstName: | MICHAEL | ||||||||
| AuthorizedOfficialMiddleName: | J | ||||||||
| AuthorizedOfficialTitleorPosition: | BUSINESS APPLICATION MANAGER | ||||||||
| AuthorizedOfficialTelephone: | 9093823080 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | Y | ||||||||
| ParentOrganizationLBN: | DEPARTMENT OF BEHAVIORAL HEALTH, SAN BERNARDINO COUNTY CA | ||||||||
| AuthorizedOfficialNamePrefix: | MR. | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 261QM0855X | ZZZ74743Z | CA | Y | Ambulatory Health Care Facilities | Clinic/Center | Adolescent and Children Mental Health |
No ID Information.