Provider Demographics
NPI:1134295702
Name:COUNTY OF RIVERSIDE
Entity Type:Organization
Organization Name:COUNTY OF RIVERSIDE
Other - Org Name:INDIO SUBSTANCE USE PROGRAM
Other - Org Type:Doing Business As
Authorized Official - Title/Position:DIRECTOR, DEPT. OF MENTAL HEALTH
Authorized Official - Prefix:MR
Authorized Official - First Name:JERRY
Authorized Official - Middle Name:A
Authorized Official - Last Name:WENGERD
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:951-358-4501
Mailing Address - Street 1:4095 COUNTY CIRCLE DR
Mailing Address - Street 2:
Mailing Address - City:RIVERSIDE
Mailing Address - State:CA
Mailing Address - Zip Code:92503-3410
Mailing Address - Country:US
Mailing Address - Phone:951-358-6900
Mailing Address - Fax:951-358-6905
Practice Address - Street 1:83912 AVENUE 45
Practice Address - Street 2:SUITE 9
Practice Address - City:INDIO
Practice Address - State:CA
Practice Address - Zip Code:92201-3338
Practice Address - Country:US
Practice Address - Phone:760-347-0754
Practice Address - Fax:760-347-8507
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-11-27
Last Update Date:2014-12-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251S00000XAgenciesCommunity/Behavioral Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA3316Medicaid
CA333316OtherCADDS