Provider Demographics
NPI:1073663662
Name:SAN BERNARDINO MOUNTAINS COMMUNITY HOSPITAL DISTRICT
Entity Type:Organization
Organization Name:SAN BERNARDINO MOUNTAINS COMMUNITY HOSPITAL DISTRICT
Other - Org Name:MOUNTAINS COMMUNITY HOSPITAL
Other - Org Type:Doing Business As
Authorized Official - Title/Position:CFO
Authorized Official - Prefix:MS
Authorized Official - First Name:YVONNE
Authorized Official - Middle Name:D
Authorized Official - Last Name:WAGGENER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:909-336-3651
Mailing Address - Street 1:PO BOX 70
Mailing Address - Street 2:
Mailing Address - City:LAKE ARROWHEAD
Mailing Address - State:CA
Mailing Address - Zip Code:92352-0070
Mailing Address - Country:US
Mailing Address - Phone:909-336-3651
Mailing Address - Fax:909-336-1179
Practice Address - Street 1:29101 HOSPITAL RD
Practice Address - Street 2:
Practice Address - City:LAKE ARROWHEAD
Practice Address - State:CA
Practice Address - Zip Code:92352-0070
Practice Address - Country:US
Practice Address - Phone:909-336-3651
Practice Address - Fax:909-336-1179
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-01-12
Last Update Date:2023-08-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAHSP30260I275N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes275N00000XHospital UnitsMedicare Defined Swing Bed Unit
Provider Identifiers
StateIdentifier IDID TypeIssuer
CALTC30260IMedicaid
CA05Z312Medicare Oscar/Certification