Provider Demographics
NPI:1396859179
Name:COUNTY OF RIVERSIDE
Entity Type:Organization
Organization Name:COUNTY OF RIVERSIDE
Other - Org Name:LAKE ELSINORE 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 1:2499 E LAKESHORE DR
Practice Address - Street 2:
Practice Address - City:LAKE ELSINORE
Practice Address - State:CA
Practice Address - Zip Code:92530-4446
Practice Address - Country:US
Practice Address - Phone:951-471-4200
Practice Address - Fax:951-471-4205
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-08-18
Last Update Date:2009-06-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
251K00000X
CA250000542261QF0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QF0400XAmbulatory Health Care FacilitiesClinic/CenterFederally Qualified Health Center (FQHC)
No251K00000XAgenciesPublic Health or Welfare
Provider Identifiers
StateIdentifier IDID TypeIssuer
CABCP70724FOtherCANCER DETECTION PROGRAM
CAFHC70724FMedicaid
CAHAP70724FOtherFAMILY PACT
CAHAP70724FOtherFAMILY PACT