Provider Demographics
NPI:1881256857
Name:TONY DEMICO HARRIS MBR
Entity type:Organization
Organization Name:TONY DEMICO HARRIS MBR
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CHIEF EXECTIVE OFFICER
Authorized Official - Prefix:
Authorized Official - First Name:TONY
Authorized Official - Middle Name:
Authorized Official - Last Name:HARRIS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:909-756-3583
Mailing Address - Street 1:8052 TUSCANY ST
Mailing Address - Street 2:
Mailing Address - City:FONTANA
Mailing Address - State:CA
Mailing Address - Zip Code:92336-3800
Mailing Address - Country:US
Mailing Address - Phone:909-756-3583
Mailing Address - Fax:
Practice Address - Street 1:8052 TUSCANY ST
Practice Address - Street 2:
Practice Address - City:FONTANA
Practice Address - State:CA
Practice Address - Zip Code:92336-3800
Practice Address - Country:US
Practice Address - Phone:909-756-3583
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2019-07-01
Last Update Date:2019-07-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes302F00000XManaged Care OrganizationsExclusive Provider Organization
No103G00000XBehavioral Health & Social Service ProvidersClinical NeuropsychologistGroup - Multi-Specialty
No177F00000XOther Service ProvidersLodging
No251300000XAgenciesLocal Education Agency (LEA)
No251B00000XAgenciesCase Management
No251C00000XAgenciesDay Training, Developmentally Disabled Services
No251E00000XAgenciesHome Health
No251T00000XAgenciesProgram of All-Inclusive Care for the Elderly (PACE) Provider Organization
No251X00000XAgenciesSupports Brokerage
No261QC1800XAmbulatory Health Care FacilitiesClinic/CenterCorporate Health
No261QM2800XAmbulatory Health Care FacilitiesClinic/CenterMethadone
No261QS0112XAmbulatory Health Care FacilitiesClinic/CenterOral and Maxillofacial Surgery
No305R00000XManaged Care OrganizationsPreferred Provider Organization
No320600000XResidential Treatment FacilitiesResidential Treatment Facility, Intellectual and/or Developmental Disabilities
No3336M0002XSuppliersPharmacyMail Order Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA005947OtherHEALTHCARE ALLIANCE