Provider Demographics
NPI:1023178837
Name:COMMUNITY HOSPITAL OF SAN BERNARDINO
Entity Type:Organization
Organization Name:COMMUNITY HOSPITAL OF SAN BERNARDINO
Other - Org Name:COMMUNITY HOME HEALTH OF SAN BERNARDINO
Other - Org Type:Doing Business As
Authorized Official - Title/Position:CFO
Authorized Official - Prefix:
Authorized Official - First Name:ED
Authorized Official - Middle Name:
Authorized Official - Last Name:SORENSON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:909-806-1100
Mailing Address - Street 1:1805 MEDICAL CENTER DR
Mailing Address - Street 2:
Mailing Address - City:SAN BERNARDINO
Mailing Address - State:CA
Mailing Address - Zip Code:92411-1217
Mailing Address - Country:US
Mailing Address - Phone:909-887-6391
Mailing Address - Fax:909-806-1059
Practice Address - Street 1:1805 MEDICAL CENTER DR
Practice Address - Street 2:
Practice Address - City:SAN BERNARDINO
Practice Address - State:CA
Practice Address - Zip Code:92411-1217
Practice Address - Country:US
Practice Address - Phone:909-887-6391
Practice Address - Fax:909-806-1059
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:COMMUNITY HOSPITAL OF SAN BERNARDINO
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2006-12-11
Last Update Date:2013-09-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA240000749251E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251E00000XAgenciesHome Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAHHA07432HMedicaid
CAZZZ02772ZOtherBLUE SHIELD
CAZZZ02772ZOtherBLUE SHIELD
CAHHA07432HMedicaid
CA=========924110047OtherWPSTRICARE