Provider Demographics
NPI:1922241215
Name:SAN BERNARDINO CARDIO CARE
Entity Type:Organization
Organization Name:SAN BERNARDINO CARDIO CARE
Other - Org Name:CARDIO CARE WELLNESS CENTER
Other - Org Type:Doing Business As
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:MRS
Authorized Official - First Name:JACQUELYN
Authorized Official - Middle Name:
Authorized Official - Last Name:THOMPSON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:323-294-8123
Mailing Address - Street 1:5231 ONAKNOLL AVE
Mailing Address - Street 2:
Mailing Address - City:LOS ANGELES
Mailing Address - State:CA
Mailing Address - Zip Code:90043-1041
Mailing Address - Country:US
Mailing Address - Phone:323-294-8123
Mailing Address - Fax:
Practice Address - Street 1:5231 ONAKNOLL AVE
Practice Address - Street 2:
Practice Address - City:LOS ANGELES
Practice Address - State:CA
Practice Address - Zip Code:90043-1041
Practice Address - Country:US
Practice Address - Phone:323-793-9183
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-04-16
Last Update Date:2010-05-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA261Q00000X, 343900000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261Q00000XAmbulatory Health Care FacilitiesClinic/Center
No343900000XTransportation ServicesNon-emergency Medical Transport (VAN)