Provider Demographics
NPI:1346353679
Name:COUNTY OF RIVERSIDE
Entity type:Organization
Organization Name:COUNTY OF RIVERSIDE
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:CHIEF EXECUTIVE OFFICER
Authorized Official - Prefix:
Authorized Official - First Name:JENNIFER
Authorized Official - Middle Name:
Authorized Official - Last Name:CRUIKSHANK
Authorized Official - Suffix:
Authorized Official - Credentials:RN, MSN
Authorized Official - Phone:951-486-6471
Mailing Address - Street 1:7888 MISSION GROVE PKWY S STE 120
Mailing Address - Street 2:
Mailing Address - City:RIVERSIDE
Mailing Address - State:CA
Mailing Address - Zip Code:92508-5064
Mailing Address - Country:US
Mailing Address - Phone:951-849-6749
Mailing Address - Fax:951-498-0060
Practice Address - Street 1:940 E WILLIAMS ST STE 102
Practice Address - Street 2:
Practice Address - City:BANNING
Practice Address - State:CA
Practice Address - Zip Code:92220-5848
Practice Address - Country:US
Practice Address - Phone:951-849-6794
Practice Address - Fax:951-849-0060
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-08-17
Last Update Date:2025-07-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
251K00000X
CA250000534261QF0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QF0400XAmbulatory Health Care FacilitiesClinic/CenterFederally Qualified Health Center (FQHC)
No251K00000XAgenciesPublic Health or Welfare
Provider Identifiers
StateIdentifier IDID TypeIssuer
CABCP70723FOtherCANCER DETECTION PROGRAM
CAHAP70723FOtherFAMILY PACT
CAFHC70723FMedicaid
CAFHC70723FMedicaid