Provider Demographics
NPI:1265505762
Name:COUNTY OF RIVERSIDE
Entity Type:Organization
Organization Name:COUNTY OF RIVERSIDE
Other - Org Name:LA GRANADA MEDICAL THERAPY UNIT
Other - Org Type:Doing Business As
Authorized Official - Title/Position:CMS BRANCH CHIEF
Authorized Official - Prefix:MS
Authorized Official - First Name:SUSAN
Authorized Official - Middle Name:JOHNSON
Authorized Official - Last Name:MORA
Authorized Official - Suffix:
Authorized Official - Credentials:PHN
Authorized Official - Phone:951-358-5401
Mailing Address - Street 1:PO BOX 7600
Mailing Address - Street 2:
Mailing Address - City:RIVERSIDE
Mailing Address - State:CA
Mailing Address - Zip Code:92513-7600
Mailing Address - Country:US
Mailing Address - Phone:951-358-5401
Mailing Address - Fax:951-358-5150
Practice Address - Street 1:10353 GRAMERCY PL
Practice Address - Street 2:
Practice Address - City:RIVERSIDE
Practice Address - State:CA
Practice Address - Zip Code:92505-1334
Practice Address - Country:US
Practice Address - Phone:951-687-3113
Practice Address - Fax:951-359-1747
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-11-15
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251K00000XAgenciesPublic Health or Welfare
Provider Identifiers
StateIdentifier IDID TypeIssuer
CACCS00030FOtherMEDI-CAL PROVIDER NUMBER