Provider Demographics
NPI:1346353679
Name:COUNTY OF RIVERSIDE
Entity Type:Organization
Organization Name:COUNTY OF RIVERSIDE
Other - Org Name:BANNING HEALTH CARE
Other - Org Type:Other Name
Authorized Official - Title/Position:DEPUTY DIRECTOR
Authorized Official - Prefix:MRS
Authorized Official - First Name:KOEN
Authorized Official - Middle Name:
Authorized Official - Last Name:BROWN
Authorized Official - Suffix:
Authorized Official - Credentials:RN, MSN
Authorized Official - Phone:951-358-5222
Mailing Address - Street 1:PO BOX 7849
Mailing Address - Street 2:
Mailing Address - City:RIVERSIDE
Mailing Address - State:CA
Mailing Address - Zip Code:92513-7849
Mailing Address - Country:US
Mailing Address - Phone:951-358-5222
Mailing Address - Fax:951-358-5235
Practice Address - Street 1:3055 W RAMSEY ST
Practice Address - Street 2:
Practice Address - City:BANNING
Practice Address - State:CA
Practice Address - Zip Code:92220-3781
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:2009-06-12
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
CAHAP70723FOtherFAMILY PACT
CABCP70723FOtherCANCER DETECTION PROGRAM
CAFHC70723FMedicaid
CAFHC70723FMedicaid