Provider Demographics
NPI:1669681961
Name:WEST VALLEY FAST
Entity Type:Organization
Organization Name:WEST VALLEY FAST
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:BUSINESS APPLICATION MANAGER
Authorized Official - Prefix:MR
Authorized Official - First Name:MICHAEL
Authorized Official - Middle Name:J
Authorized Official - Last Name:DAY
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:909-382-3080
Mailing Address - Street 1:268 W HOSPITALITY LN
Mailing Address - Street 2:SUITE 400
Mailing Address - City:SAN BERNARDINO
Mailing Address - State:CA
Mailing Address - Zip Code:92415-0001
Mailing Address - Country:US
Mailing Address - Phone:909-382-3080
Mailing Address - Fax:909-382-3105
Practice Address - Street 1:9478 ETIWANDA AVE
Practice Address - Street 2:
Practice Address - City:RANCHO CUCAMONGA
Practice Address - State:CA
Practice Address - Zip Code:91739-9662
Practice Address - Country:US
Practice Address - Phone:909-382-3080
Practice Address - Fax:909-382-3105
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:DEPARTMENT OF BEHAVIORAL HEALTH, SAN BERNARDINO COUNTY CA
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2007-05-22
Last Update Date:2007-07-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAZZZ74743Z261QM0855X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QM0855XAmbulatory Health Care FacilitiesClinic/CenterAdolescent and Children Mental Health