Provider Demographics
NPI:1982756086
Name:COMMUNITY HEALTH SYSTEMS INC
Entity Type:Organization
Organization Name:COMMUNITY HEALTH SYSTEMS INC
Other - Org Name:FALLBROOK FAMILY HEALTH CENTER
Other - Org Type:Doing Business As
Authorized Official - Title/Position:CHIEF EXECUTIVE OFFICER
Authorized Official - Prefix:
Authorized Official - First Name:JACK
Authorized Official - Middle Name:E
Authorized Official - Last Name:JOHNS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:951-571-2300
Mailing Address - Street 1:22675 ALESSANDRO BLVD
Mailing Address - Street 2:
Mailing Address - City:MORENO VALLEY
Mailing Address - State:CA
Mailing Address - Zip Code:92553-8551
Mailing Address - Country:US
Mailing Address - Phone:951-571-2300
Mailing Address - Fax:951-571-2330
Practice Address - Street 1:1328 S MISSION RD
Practice Address - Street 2:
Practice Address - City:FALLBROOK
Practice Address - State:CA
Practice Address - Zip Code:92028-4006
Practice Address - Country:US
Practice Address - Phone:760-451-4720
Practice Address - Fax:760-451-4700
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-01-17
Last Update Date:2011-09-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA524281223G0001X
CAOPT5169TPA152W00000X
CAA78623207Q00000X
CAC53673207Q00000X
CAA90249207Q00000X
CA7619207Q00000X
CAC36017207R00000X
CA1846207V00000X
CA350902207V00000X
CAA63365207V00000X
CALM235207V00000X
CAA1153422084N0400X
CAA1148572084N0400X
CAA1020332084P0800X
CA080000150261QF0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes261QF0400XAmbulatory Health Care FacilitiesClinic/CenterFederally Qualified Health Center (FQHC)
No1223G0001XDental ProvidersDentistGeneral PracticeGroup - Multi-Specialty
No152W00000XEye and Vision Services ProvidersOptometristGroup - Multi-Specialty
No207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Multi-Specialty
No207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Multi-Specialty
No207V00000XAllopathic & Osteopathic PhysiciansObstetrics & GynecologyGroup - Multi-Specialty
No2084N0400XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyNeurologyGroup - Multi-Specialty
No2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatryGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA4998231Medicaid
CAEAP70324FMedicaid
CABCP70275GOtherBCDEP
CACK277BOtherMEDICARE
CAHAP70275GMedicaid
CA4998231Medicaid
CA551853Medicare PIN