Provider Demographics
NPI:1437784410
Name:SAC HEALTH SYSTEM
Entity Type:Organization
Organization Name:SAC HEALTH SYSTEM
Other - Org Name:SAC MOBILE UNIT #1
Other - Org Type:Other Name
Authorized Official - Title/Position:DIRECTOR OF BILLING
Authorized Official - Prefix:
Authorized Official - First Name:TASHA
Authorized Official - Middle Name:
Authorized Official - Last Name:AMICK
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:909-382-7180
Mailing Address - Street 1:250 S G ST
Mailing Address - Street 2:
Mailing Address - City:SAN BERNARDINO
Mailing Address - State:CA
Mailing Address - Zip Code:92410-3320
Mailing Address - Country:US
Mailing Address - Phone:909-382-7180
Mailing Address - Fax:909-382-7100
Practice Address - Street 1:250 S G ST
Practice Address - Street 2:
Practice Address - City:SAN BERNARDINO
Practice Address - State:CA
Practice Address - Zip Code:92410-3320
Practice Address - Country:US
Practice Address - Phone:909-382-7100
Practice Address - Fax:909-382-7100
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:SAC HEALTH SYSTEM
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2020-03-10
Last Update Date:2022-09-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QF0400XAmbulatory Health Care FacilitiesClinic/CenterFederally Qualified Health Center (FQHC)
No261QC1500XAmbulatory Health Care FacilitiesClinic/CenterCommunity Health
No261QD0000XAmbulatory Health Care FacilitiesClinic/CenterDental
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAEAP70708FOtherEAPC
CACMM70708FMedicaid
CAENVOY3000OtherENVOY SITE ID