Provider Demographics
NPI:1720105059
Name:RIVERSIDE COUNTY DEPARTMENT OF MENTAL HEALTH
Entity Type:Organization
Organization Name:RIVERSIDE COUNTY DEPARTMENT OF MENTAL HEALTH
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DIRECTOR
Authorized Official - Prefix:MR
Authorized Official - First Name:JERRY
Authorized Official - Middle Name:ALLEN
Authorized Official - Last Name:WENGERD
Authorized Official - Suffix:
Authorized Official - Credentials:MSW
Authorized Official - Phone:951-358-4501
Mailing Address - Street 1:4095 COUNTY CIRCLE DR
Mailing Address - Street 2:
Mailing Address - City:RIVERSIDE
Mailing Address - State:CA
Mailing Address - Zip Code:92503-3410
Mailing Address - Country:US
Mailing Address - Phone:951-358-4501
Mailing Address - Fax:951-358-4513
Practice Address - Street 1:4095 COUNTY CIRCLE DR
Practice Address - Street 2:
Practice Address - City:RIVERSIDE
Practice Address - State:CA
Practice Address - Zip Code:92503-3410
Practice Address - Country:US
Practice Address - Phone:951-358-4501
Practice Address - Fax:951-358-4513
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-03-23
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CALCS6297261Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261Q00000XAmbulatory Health Care FacilitiesClinic/Center