Provider Demographics
NPI:1205940145
Name:COUNTY OF RIVERSIDE
Entity type:Organization
Organization Name:COUNTY OF RIVERSIDE
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:SECRETARY
Authorized Official - Prefix:
Authorized Official - First Name:YOSELI
Authorized Official - Middle Name:NOEMI
Authorized Official - Last Name:JIMENEZ
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:951-358-6278
Mailing Address - Street 1:PO BOX 7849
Mailing Address - Street 2:
Mailing Address - City:RIVERSIDE
Mailing Address - State:CA
Mailing Address - Zip Code:92513-7849
Mailing Address - Country:US
Mailing Address - Phone:951-358-5222
Mailing Address - Fax:951-358-5235
Practice Address - Street 1:2813 S MAIN ST
Practice Address - Street 2:
Practice Address - City:CORONA
Practice Address - State:CA
Practice Address - Zip Code:92882
Practice Address - Country:US
Practice Address - Phone:951-272-5445
Practice Address - Fax:951-272-5489
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-08-18
Last Update Date:2018-06-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
251K00000X
CA250000536261QF0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QF0400XAmbulatory Health Care FacilitiesClinic/CenterFederally Qualified Health Center (FQHC)
No251K00000XAgenciesPublic Health or Welfare
Provider Identifiers
StateIdentifier IDID TypeIssuer
CABCP70548FOtherCANCER DETECTION PROGRAM
CAHAP70548FOtherFAMILY PACT
CAHAP70548FOtherFAMILY PACT
CABCP70548FOtherCANCER DETECTION PROGRAM