Provider Demographics
NPI:1558702142
Name:SAN BERNARDINO HOSPICE LLC
Entity Type:Organization
Organization Name:SAN BERNARDINO HOSPICE LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO/PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:DESIREE
Authorized Official - Middle Name:
Authorized Official - Last Name:BRADFORD
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:951-310-8367
Mailing Address - Street 1:13139 CENTRAL AVE
Mailing Address - Street 2:SUITE E
Mailing Address - City:CHINO
Mailing Address - State:CA
Mailing Address - Zip Code:91710-4126
Mailing Address - Country:US
Mailing Address - Phone:951-310-8367
Mailing Address - Fax:909-628-4665
Practice Address - Street 1:13139 CENTRAL AVE
Practice Address - Street 2:SUITE E
Practice Address - City:CHINO
Practice Address - State:CA
Practice Address - Zip Code:91710-4126
Practice Address - Country:US
Practice Address - Phone:951-310-8367
Practice Address - Fax:909-628-4665
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2013-07-10
Last Update Date:2016-10-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251G00000XAgenciesHospice Care, Community Based
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA550002550OtherCDPH HOSPICE LICENSE