Provider Demographics
NPI:1508157520
Name:BLOOD BANK OF SAN BERNARDINO AND RIVERSIDE COUNTIES
Entity Type:Organization
Organization Name:BLOOD BANK OF SAN BERNARDINO AND RIVERSIDE COUNTIES
Other - Org Name:LIFESTREAM
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PRESIDENT/CEO/MEDICAL DIRECTOR
Authorized Official - Prefix:DR
Authorized Official - First Name:FREDERICK
Authorized Official - Middle Name:B
Authorized Official - Last Name:AXELROD
Authorized Official - Suffix:
Authorized Official - Credentials:MD , MBA
Authorized Official - Phone:909-885-6503
Mailing Address - Street 1:PO BOX 5729
Mailing Address - Street 2:
Mailing Address - City:SAN BERNARDINO
Mailing Address - State:CA
Mailing Address - Zip Code:92412-5729
Mailing Address - Country:US
Mailing Address - Phone:909-885-6503
Mailing Address - Fax:909-381-2036
Practice Address - Street 1:384 W ORANGE SHOW RD
Practice Address - Street 2:
Practice Address - City:SAN BERNARDINO
Practice Address - State:CA
Practice Address - Zip Code:92408-2028
Practice Address - Country:US
Practice Address - Phone:909-885-6503
Practice Address - Fax:909-381-2036
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-04-25
Last Update Date:2011-04-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CACLF3556291U00000X
CA9021331L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes331L00000XSuppliersBlood Bank
No291U00000XLaboratoriesClinical Medical Laboratory
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAZZZ84738ZMedicare PIN