Basic Information
| Provider Information | |||||||||
| NPI: | 1902562416 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | SOUTHERN INDIAN HEALTH COUNCIL INC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 8 CRESTWOOD RD | ||||||||
| Address2: | |||||||||
| City: | BOULEVARD | ||||||||
| State: | CA | ||||||||
| PostalCode: | 919059725 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6194451188 | ||||||||
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| Practice Location | |||||||||
| Address1: | 8 CRESTWOOD RD | ||||||||
| Address2: | |||||||||
| City: | BOULEVARD | ||||||||
| State: | CA | ||||||||
| PostalCode: | 919059725 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6194451188 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 11/10/2021 | ||||||||
| LastUpdateDate: | 11/10/2021 | ||||||||
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| AuthorizedOfficialLastName: | DIZON | ||||||||
| AuthorizedOfficialFirstName: | MARIE | ||||||||
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| AuthorizedOfficialTitleorPosition: | LEAD BILLER | ||||||||
| AuthorizedOfficialTelephone: | 6194451188 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | Y | ||||||||
| ParentOrganizationLBN: | SOUTHERN INDIAN HEALTH COUNCIL INC | ||||||||
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| NPICertificationDate: | 10/26/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 261QR0401X | Y | Ambulatory Health Care Facilities | Clinic/Center | Rehabilitation, Comprehensive Outpatient Rehabilitation Facility (CORF) |
ID Information
| ID | Type | State | Issuer | Description | W7576A | 01 | CA | MEDICARE | OTHER | THP70010F | 05 | CA | MEDICAID |