Provider Demographics
NPI:1629264775
Name:JERRY L. PETTIS VA MEMORIAL HOSPITAL
Entity Type:Organization
Organization Name:JERRY L. PETTIS VA MEMORIAL HOSPITAL
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:MR
Authorized Official - First Name:DEAN
Authorized Official - Middle Name:
Authorized Official - Last Name:STORDAHL
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:909-825-7084
Mailing Address - Street 1:19845 SAN LUIS REY LN
Mailing Address - Street 2:
Mailing Address - City:RIVERSIDE
Mailing Address - State:CA
Mailing Address - Zip Code:92508-6494
Mailing Address - Country:US
Mailing Address - Phone:951-653-7051
Mailing Address - Fax:
Practice Address - Street 1:19845 SAN LUIS REY LN
Practice Address - Street 2:
Practice Address - City:RIVERSIDE
Practice Address - State:CA
Practice Address - Zip Code:92508-6494
Practice Address - Country:US
Practice Address - Phone:951-653-7051
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-09-22
Last Update Date:2007-09-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA219193283Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes283Q00000XHospitalsPsychiatric Hospital