Provider Demographics
NPI:1073744660
Name:INLAND VALLEY DRUG AND ALCOHOL RECOVERY SERVICES
Entity Type:Organization
Organization Name:INLAND VALLEY DRUG AND ALCOHOL RECOVERY SERVICES
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CHIEF EXECUTIVE OFFICER
Authorized Official - Prefix:
Authorized Official - First Name:TINA
Authorized Official - Middle Name:K
Authorized Official - Last Name:HUGHES
Authorized Official - Suffix:
Authorized Official - Credentials:BS, LAADC-CA
Authorized Official - Phone:909-932-1069
Mailing Address - Street 1:1260 E ARROW HWY
Mailing Address - Street 2:
Mailing Address - City:UPLAND
Mailing Address - State:CA
Mailing Address - Zip Code:91786-4982
Mailing Address - Country:US
Mailing Address - Phone:909-932-1069
Mailing Address - Fax:909-932-1087
Practice Address - Street 1:939 N D ST
Practice Address - Street 2:
Practice Address - City:SAN BERNARDINO
Practice Address - State:CA
Practice Address - Zip Code:92410-3519
Practice Address - Country:US
Practice Address - Phone:909-889-6519
Practice Address - Fax:909-889-6560
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-07-31
Last Update Date:2023-12-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA36001AAN261QR0401X
CA360001ABN261QR0405X, 261QR0405X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QR0405XAmbulatory Health Care FacilitiesClinic/CenterRehabilitation, Substance Use Disorder
No261QR0401XAmbulatory Health Care FacilitiesClinic/CenterRehabilitation, Comprehensive Outpatient Rehabilitation Facility (CORF)
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA005284Medicare UPIN