Basic Information
| Provider Information | |||||||||
| NPI: | 1720105059 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | RIVERSIDE COUNTY DEPARTMENT OF MENTAL HEALTH | ||||||||
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| Mailing Information | |||||||||
| Address1: | 4095 COUNTY CIRCLE DR | ||||||||
| Address2: | |||||||||
| City: | RIVERSIDE | ||||||||
| State: | CA | ||||||||
| PostalCode: | 925033410 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9513584501 | ||||||||
| FaxNumber: | 9513584513 | ||||||||
| Practice Location | |||||||||
| Address1: | 4095 COUNTY CIRCLE DR | ||||||||
| Address2: | |||||||||
| City: | RIVERSIDE | ||||||||
| State: | CA | ||||||||
| PostalCode: | 925033410 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9513584501 | ||||||||
| FaxNumber: | 9513584513 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 03/23/2007 | ||||||||
| LastUpdateDate: | 08/22/2020 | ||||||||
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| AuthorizedOfficialLastName: | WENGERD | ||||||||
| AuthorizedOfficialFirstName: | JERRY | ||||||||
| AuthorizedOfficialMiddleName: | ALLEN | ||||||||
| AuthorizedOfficialTitleorPosition: | DIRECTOR | ||||||||
| AuthorizedOfficialTelephone: | 9513584501 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | MR. | ||||||||
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| AuthorizedOfficialCredential: | MSW | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 261Q00000X | LCS6297 | CA | Y | Ambulatory Health Care Facilities | Clinic/Center |
No ID Information.