Provider Demographics
NPI:1326257403
Name:COUNTY OF SAN BERNARDINO
Entity Type:Organization
Organization Name:COUNTY OF SAN BERNARDINO
Other - Org Name:LUCERNE VALLEY CLINIC
Other - Org Type:Doing Business As
Authorized Official - Title/Position:INFORMATION TECHNOLOGY MANAGER
Authorized Official - Prefix:MR
Authorized Official - First Name:MICHAEL
Authorized Official - Middle Name:J
Authorized Official - Last Name:DAY
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:909-382-3061
Mailing Address - Street 1:268 W HOSPITALITY LN
Mailing Address - Street 2:SUITE 400
Mailing Address - City:SAN BERNARDINO
Mailing Address - State:CA
Mailing Address - Zip Code:92415-0026
Mailing Address - Country:US
Mailing Address - Phone:909-382-3080
Mailing Address - Fax:909-382-3105
Practice Address - Street 1:32700 OLD WOMAN SPRINGS ROAD
Practice Address - Street 2:SUITE C
Practice Address - City:LUCERNE VALLEY
Practice Address - State:CA
Practice Address - Zip Code:92356
Practice Address - Country:US
Practice Address - Phone:909-382-3080
Practice Address - Fax:909-382-3105
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:DEPARTMENT OF BEHAVIORAL HEALTH
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2007-05-22
Last Update Date:2009-07-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAZZZ74743Z261QR0405X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QR0405XAmbulatory Health Care FacilitiesClinic/CenterRehabilitation, Substance Use Disorder
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA360003681OtherADP MEDICAL PROVIDER NUMB