Provider Demographics
NPI:1356455299
Name:COUNTY OF RIVERSIDE
Entity Type:Organization
Organization Name:COUNTY OF RIVERSIDE
Other - Org Name:RUBIDOUX FAMILY CARE CENTER
Other - Org Type:Other Name
Authorized Official - Title/Position:DEPUTY DIRECTOR II
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 1:5256 MISSION BLVD
Practice Address - Street 2:
Practice Address - City:RIVERSIDE
Practice Address - State:CA
Practice Address - Zip Code:92509-4611
Practice Address - Country:US
Practice Address - Phone:951-955-0840
Practice Address - Fax:951-955-5317
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-08-18
Last Update Date:2009-06-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA251K00000X, 261QD0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251K00000XAgenciesPublic Health or Welfare
No261QD0000XAmbulatory Health Care FacilitiesClinic/CenterDental
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAEXE70155FMedicaid