Basic Information
| Provider Information | |||||||||
| NPI: | 1699976597 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | CHILDREN'S CRISIS RESPONSE TEAM MORONGO BASIN | ||||||||
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| Mailing Information | |||||||||
| Address1: | 268 W. HOSPITALITY LANE | ||||||||
| Address2: | SUITE 400 | ||||||||
| City: | SAN BERNARDINO | ||||||||
| State: | CA | ||||||||
| PostalCode: | 924150026 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9093823080 | ||||||||
| FaxNumber: | 9093823105 | ||||||||
| Practice Location | |||||||||
| Address1: | 56357 PIMA TRAIL | ||||||||
| Address2: | |||||||||
| City: | YUCCA VALLEY | ||||||||
| State: | CA | ||||||||
| PostalCode: | 92284 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9093823080 | ||||||||
| FaxNumber: | 9093823105 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/29/2007 | ||||||||
| LastUpdateDate: | 07/13/2007 | ||||||||
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| AuthorizedOfficialLastName: | DAY | ||||||||
| AuthorizedOfficialFirstName: | MICHAEL | ||||||||
| AuthorizedOfficialMiddleName: | J | ||||||||
| AuthorizedOfficialTitleorPosition: | INFORMATION TECHNOLOGY MANAGER | ||||||||
| AuthorizedOfficialTelephone: | 9093880570 | ||||||||
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| 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 |
ID Information
| ID | Type | State | Issuer | Description | 3600036DG | 01 | CA | MEDICAL PROVIDER NUMBER | OTHER |