Provider Demographics
NPI:1225213697
Name:FOUNDATION FOR CALIFORNIA STATE UNIVERSITY SAN BERNARDINO
Entity Type:Organization
Organization Name:FOUNDATION FOR CALIFORNIA STATE UNIVERSITY SAN BERNARDINO
Other - Org Name:START PEDIATRIC NEURODEVELOPMENTAL ASSESSMENT AND TREATMENT CENTER
Other - Org Type:Other Name
Authorized Official - Title/Position:GENERAL MANAGER
Authorized Official - Prefix:MS
Authorized Official - First Name:DEBORAH
Authorized Official - Middle Name:
Authorized Official - Last Name:BURNS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:909-537-3939
Mailing Address - Street 1:5500 UNIVERSITY PKWY
Mailing Address - Street 2:
Mailing Address - City:SAN BERNARDINO
Mailing Address - State:CA
Mailing Address - Zip Code:92407-2318
Mailing Address - Country:US
Mailing Address - Phone:909-537-3939
Mailing Address - Fax:
Practice Address - Street 1:165 W HOSPITALITY LN
Practice Address - Street 2:SUITE 12
Practice Address - City:SAN BERNARDINO
Practice Address - State:CA
Practice Address - Zip Code:92408-3334
Practice Address - Country:US
Practice Address - Phone:909-891-1880
Practice Address - Fax:909-891-1888
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-01-04
Last Update Date:2008-01-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251S00000XAgenciesCommunity/Behavioral Health
No251B00000XAgenciesCase Management
No252Y00000XAgenciesEarly Intervention Provider Agency