Basic Information
| Provider Information | |||||||||
| NPI: | 1821209743 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | COUNTY OF SAN BERNARDINO | ||||||||
| LastName: | |||||||||
| FirstName: | |||||||||
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| Credential: | |||||||||
| OtherOrganizationName: | NUEVA VIDA | ||||||||
| OtherOrganizationType: | 3 | ||||||||
| OtherLastName: | |||||||||
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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: | 290 N 10TH ST | ||||||||
| Address2: | SUITE 102 | ||||||||
| City: | COLTON | ||||||||
| State: | CA | ||||||||
| PostalCode: | 923243052 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9093823080 | ||||||||
| FaxNumber: | 9093823105 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/24/2007 | ||||||||
| LastUpdateDate: | 09/24/2009 | ||||||||
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| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | DAY | ||||||||
| AuthorizedOfficialFirstName: | MICHAEL | ||||||||
| AuthorizedOfficialMiddleName: | J. | ||||||||
| AuthorizedOfficialTitleorPosition: | INFORMATION TECHNOLOGY MANAGER | ||||||||
| AuthorizedOfficialTelephone: | 9093880570 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | Y | ||||||||
| ParentOrganizationLBN: | DEPARTMENT OF BEHAVIORAL HEALTH | ||||||||
| AuthorizedOfficialNamePrefix: | MR. | ||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
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| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 261QM0801X | ZZZ74743Z | CA | Y | Ambulatory Health Care Facilities | Clinic/Center | Mental Health (Including Community Mental Health Center) |
ID Information
| ID | Type | State | Issuer | Description | 360003693 | 01 | CA | MEDICAL PROVIDER NUMBER | OTHER |