Provider Demographics
NPI:1437202124
Name:RIVERSIDE-SAN BERNARDINO COUNTY INDIAN HEALTH, INC
Entity Type:Organization
Organization Name:RIVERSIDE-SAN BERNARDINO COUNTY INDIAN HEALTH, INC
Other - Org Name:MORONGO INDIAN HEALTH
Other - Org Type:Doing Business As
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:
Authorized Official - First Name:WILLIAM
Authorized Official - Middle Name:
Authorized Official - Last Name:THOMSEN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:909-864-1097
Mailing Address - Street 1:11980 MOUNT VERNON AVE
Mailing Address - Street 2:
Mailing Address - City:GRAND TERRACE
Mailing Address - State:CA
Mailing Address - Zip Code:92313-5172
Mailing Address - Country:US
Mailing Address - Phone:909-864-1097
Mailing Address - Fax:909-744-3960
Practice Address - Street 1:11555 1/2 POTRERO RD
Practice Address - Street 2:
Practice Address - City:BANNING
Practice Address - State:CA
Practice Address - Zip Code:92220-6946
Practice Address - Country:US
Practice Address - Phone:951-849-4761
Practice Address - Fax:951-849-5612
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-01-18
Last Update Date:2021-08-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QF0400XAmbulatory Health Care FacilitiesClinic/CenterFederally Qualified Health Center (FQHC)
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAFHC03854FMedicaid
CA05-1909Medicare ID - Type Unspecified