Provider Demographics
NPI:1821209743
Name:COUNTY OF SAN BERNARDINO
Entity Type:Organization
Organization Name:COUNTY OF SAN BERNARDINO
Other - Org Name:NUEVA VIDA
Other - Org Type:Doing Business As
Authorized Official - Title/Position:INFORMATION TECHNOLOGY 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:909-388-0570
Mailing Address - Street 1:268 W. HOSPITALITY LANE
Mailing Address - Street 2:SUITE 400
Mailing Address - City:SAN BERNARDINO
Mailing Address - State:CA
Mailing Address - Zip Code:92415-0026
Mailing Address - Country:US
Mailing Address - Phone:909-382-3080
Mailing Address - Fax:909-382-3105
Practice Address - Street 1:290 N 10TH ST
Practice Address - Street 2:SUITE 102
Practice Address - City:COLTON
Practice Address - State:CA
Practice Address - Zip Code:92324-3052
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
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2007-05-24
Last Update Date:2009-09-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAZZZ74743Z261QM0801X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QM0801XAmbulatory Health Care FacilitiesClinic/CenterMental Health (Including Community Mental Health Center)
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA360003693OtherMEDICAL PROVIDER NUMBER
CAZZZ21934ZMedicare PIN