Basic Information
| Provider Information | |||||||||
| NPI: | 1982756086 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | COMMUNITY HEALTH SYSTEMS INC | ||||||||
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| OtherOrganizationName: | FALLBROOK FAMILY HEALTH CENTER | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 22675 ALESSANDRO BLVD | ||||||||
| Address2: | |||||||||
| City: | MORENO VALLEY | ||||||||
| State: | CA | ||||||||
| PostalCode: | 925538551 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9515712300 | ||||||||
| FaxNumber: | 9515712330 | ||||||||
| Practice Location | |||||||||
| Address1: | 1328 S MISSION RD | ||||||||
| Address2: | |||||||||
| City: | FALLBROOK | ||||||||
| State: | CA | ||||||||
| PostalCode: | 920284006 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7604514720 | ||||||||
| FaxNumber: | 7604514700 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 01/17/2007 | ||||||||
| LastUpdateDate: | 09/02/2011 | ||||||||
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| AuthorizedOfficialLastName: | JOHNS | ||||||||
| AuthorizedOfficialFirstName: | JACK | ||||||||
| AuthorizedOfficialMiddleName: | E | ||||||||
| AuthorizedOfficialTitleorPosition: | CHIEF EXECUTIVE OFFICER | ||||||||
| AuthorizedOfficialTelephone: | 9515712300 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207V00000X | A63365 | CA | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Obstetrics & Gynecology | 1223G0001X | 52428 | CA | N | 193200000X MULTI-SPECIALTY GROUP | Dental Providers | Dentist | General Practice | 152W00000X | OPT5169TPA | CA | N | 193200000X MULTI-SPECIALTY GROUP | Eye and Vision Services Providers | Optometrist | 207Q00000X | A78623 | CA | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Family Medicine | 207Q00000X | C53673 | CA | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Family Medicine | 207Q00000X | A90249 | CA | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Family Medicine | 207Q00000X | 7619 | CA | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Family Medicine | 207R00000X | C36017 | CA | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Internal Medicine | 207V00000X | 1846 | CA | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Obstetrics & Gynecology | 207V00000X | 350902 | CA | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Obstetrics & Gynecology | 207V00000X | LM235 | CA | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Obstetrics & Gynecology | 2084N0400X | A115342 | CA | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Psychiatry & Neurology | Neurology | 2084N0400X | A114857 | CA | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Psychiatry & Neurology | Neurology | 2084P0800X | A102033 | CA | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Psychiatry & Neurology | Psychiatry | 261QF0400X | 080000150 | CA | Y | Ambulatory Health Care Facilities | Clinic/Center | Federally Qualified Health Center (FQHC) |
ID Information
| ID | Type | State | Issuer | Description | 4998231 | 05 | CA | MEDICAID | EAP70324F | 05 | CA | MEDICAID | BCP70275G | 01 | CA | BCDEP | OTHER | CK277B | 01 | CA | MEDICARE | OTHER | HAP70275G | 05 | CA | MEDICAID |