Basic Information
| Provider Information | |||||||||
| NPI: | 1952308009 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | COMMUNITY HEALTH SYSTEMS, INC. | ||||||||
| LastName: | |||||||||
| FirstName: | |||||||||
| MiddleName: | |||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | |||||||||
| OtherOrganizationName: | INLAND EMPIRE COMMUNITY HEALTH CENTER | ||||||||
| OtherOrganizationType: | 3 | ||||||||
| OtherLastName: | |||||||||
| OtherFirstName: | |||||||||
| OtherMiddleName: | |||||||||
| OtherNamePrefix: | |||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | |||||||||
| OtherLastNameType: | |||||||||
| Mailing Information | |||||||||
| Address1: | 18601 VALLEY BLVD | ||||||||
| Address2: | |||||||||
| City: | BLOOMINGTON | ||||||||
| State: | CA | ||||||||
| PostalCode: | 923161831 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9098771818 | ||||||||
| FaxNumber: | 9097460400 | ||||||||
| Practice Location | |||||||||
| Address1: | 18601 VALLEY BLVD | ||||||||
| Address2: | |||||||||
| City: | BLOOMINGTON | ||||||||
| State: | CA | ||||||||
| PostalCode: | 923161831 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9098771818 | ||||||||
| FaxNumber: | 9097460400 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/05/2005 | ||||||||
| LastUpdateDate: | 08/22/2020 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
| NPIDeactivationDate: | |||||||||
| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | VASCOVICH | ||||||||
| AuthorizedOfficialFirstName: | BOBBY | ||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | CHIEF EXECUTIVE OFFICER | ||||||||
| AuthorizedOfficialTelephone: | 9098771818 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | MR. | ||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 261QF0400X | CA | N | Ambulatory Health Care Facilities | Clinic/Center | Federally Qualified Health Center (FQHC) | 261QF0400X | CA | N | Ambulatory Health Care Facilities | Clinic/Center | Federally Qualified Health Center (FQHC) | 261QF0400X | CA | N | Ambulatory Health Care Facilities | Clinic/Center | Federally Qualified Health Center (FQHC) | 261QF0400X | CA | Y | Ambulatory Health Care Facilities | Clinic/Center | Federally Qualified Health Center (FQHC) |
ID Information
| ID | Type | State | Issuer | Description | G98054-01 | 01 | CA | DELTA DENTAL | OTHER | G98054-03 | 01 | CA | DELTA DENTAL | OTHER | HAP70865F | 01 | CA | FAMILY PACT | OTHER | HAP70324F | 01 | CA | FAMILY PACT | OTHER | FHC70275G | 05 | CA | MEDICAID | FHC70324F | 05 | CA | MEDICAID | FHC71040F | 05 | CA | MEDICAID | G98054-02 | 01 | CA | DELTA DENTAL | OTHER | HAP70275G | 01 | CA | FAMILY PACT | OTHER | FHC70865F | 05 | CA | MEDICAID |