Provider Demographics
NPI:1477633295
Name:KNOLLWOOD PSYCHIATRIC HOSPITAL & CHEMICAL DEPENDENCY CENTER INC
Entity Type:Organization
Organization Name:KNOLLWOOD PSYCHIATRIC HOSPITAL & CHEMICAL DEPENDENCY CENTER INC
Other - Org Name:RIVERSIDE CENTER FOR BEHAVIORAL MEDICINE
Other - Org Type:Doing Business As
Authorized Official - Title/Position:ASSIST. BUSINESS OFFICE MANAGER
Authorized Official - Prefix:MRS
Authorized Official - First Name:LISA
Authorized Official - Middle Name:
Authorized Official - Last Name:KENNEDY
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:951-275-8400
Mailing Address - Street 1:5900 BROCKTON AVE
Mailing Address - Street 2:
Mailing Address - City:RIVERSIDE
Mailing Address - State:CA
Mailing Address - Zip Code:92506-1862
Mailing Address - Country:US
Mailing Address - Phone:951-275-8400
Mailing Address - Fax:951-788-4136
Practice Address - Street 1:5900 BROCKTON AVE
Practice Address - Street 2:
Practice Address - City:RIVERSIDE
Practice Address - State:CA
Practice Address - Zip Code:92506-1862
Practice Address - Country:US
Practice Address - Phone:951-275-8400
Practice Address - Fax:951-788-4136
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-10-16
Last Update Date:2014-02-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA2500476283Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes283Q00000XHospitalsPsychiatric Hospital
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAHSP34130GMedicaid
CAHSP44130GMedicaid
CAHSP44130GMedicaid