Provider Demographics
NPI:1174676670
Name:RIVERSIDE-SAN BERNARDINO COUNTY INDIAN HEALTH, INC.
Entity Type:Organization
Organization Name:RIVERSIDE-SAN BERNARDINO COUNTY INDIAN HEALTH, INC.
Other - Org Name:SAN MANUEL INDIAN HEALTH
Other - Org Type:Doing Business As
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:
Authorized Official - First Name:WILLIAM
Authorized Official - Middle Name:
Authorized Official - Last Name:THOMSEN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:909-864-1097
Mailing Address - Street 1:11980 MOUNT VERNON AVE
Mailing Address - Street 2:
Mailing Address - City:GRAND TERRACE
Mailing Address - State:CA
Mailing Address - Zip Code:92313-5172
Mailing Address - Country:US
Mailing Address - Phone:909-864-1097
Mailing Address - Fax:909-744-3960
Practice Address - Street 1:11980 MOUNT VERNON AVE
Practice Address - Street 2:
Practice Address - City:GRAND TERRACE
Practice Address - State:CA
Practice Address - Zip Code:92313-5172
Practice Address - Country:US
Practice Address - Phone:909-864-1097
Practice Address - Fax:909-744-3960
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-01-19
Last Update Date:2021-08-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA240000751261QF0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QF0400XAmbulatory Health Care FacilitiesClinic/CenterFederally Qualified Health Center (FQHC)
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAFHC03869FMedicaid
CA05-1914Medicare ID - Type UnspecifiedMEDICARE