Provider Demographics
NPI:1003939711
Name:SAN GORGONIO MEMORIAL HOSPITAL
Entity Type:Organization
Organization Name:SAN GORGONIO MEMORIAL HOSPITAL
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:MR
Authorized Official - First Name:JONATHAN
Authorized Official - Middle Name:
Authorized Official - Last Name:BRENN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:951-769-2100
Mailing Address - Street 1:600 N HIGHLAND SPRINGS AVE
Mailing Address - Street 2:
Mailing Address - City:BANNING
Mailing Address - State:CA
Mailing Address - Zip Code:92220-3046
Mailing Address - Country:US
Mailing Address - Phone:951-845-1121
Mailing Address - Fax:951-469-0431
Practice Address - Street 1:600 N HIGHLAND SPRINGS AVE
Practice Address - Street 2:
Practice Address - City:BANNING
Practice Address - State:CA
Practice Address - Zip Code:92220-3046
Practice Address - Country:US
Practice Address - Phone:951-845-1121
Practice Address - Fax:951-469-0431
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-04-09
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CACA250001668314000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes314000000XNursing & Custodial Care FacilitiesSkilled Nursing Facility
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA555722OtherMEDICARE SNF PROVIDER NO
CALTC555722FOtherMEDICAID SNF PROVIDER NO