Provider Demographics
NPI:1982243812
Name:COUNTY OF RIVERSIDE
Entity Type:Organization
Organization Name:COUNTY OF RIVERSIDE
Other - Org Name:MAIN CAMPUS COMMUNITY HEALTH CENTER
Other - Org Type:Other Name
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:
Authorized Official - First Name:JENNIFER
Authorized Official - Middle Name:LYNN
Authorized Official - Last Name:CRUIKSHANK
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:951-486-4458
Mailing Address - Street 1:7888 MISSION GROVE PKWY S STE 120
Mailing Address - Street 2:
Mailing Address - City:RIVERSIDE
Mailing Address - State:CA
Mailing Address - Zip Code:92508-5064
Mailing Address - Country:US
Mailing Address - Phone:951-358-5222
Mailing Address - Fax:
Practice Address - Street 1:26600 CACTUS AVE STE 300
Practice Address - Street 2:
Practice Address - City:MORENO VALLEY
Practice Address - State:CA
Practice Address - Zip Code:92555-3901
Practice Address - Country:US
Practice Address - Phone:951-988-9500
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:COUNTY OF RIVERSIDE
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2019-12-23
Last Update Date:2020-03-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QF0400XAmbulatory Health Care FacilitiesClinic/CenterFederally Qualified Health Center (FQHC)