1013272558 NPI number — COUNTY OF SAN BERNARDINO

Table of Contents

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1013272558 NPI number — COUNTY OF SAN BERNARDINO

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
COUNTY OF SAN BERNARDINO
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
FONTANA CHOICE SUBSTANCE USE DISORDER TREATMENT
Provider Other Organization Name Type Code:
3
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1013272558
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
06/17/2021
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
303 E VANDERBILT WAY
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
SAN BERNARDINO
Provider Business Mailing Address State Name:
CA
Provider Business Mailing Address Postal Code:
92415-0026
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
909-388-0900
Provider Business Mailing Address Fax Number:
909-890-0435

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
17830 ARROW BLVD
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
FONTANA
Provider Business Practice Location Address State Name:
CA
Provider Business Practice Location Address Postal Code:
92335
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
909-356-6439
Provider Business Practice Location Address Fax Number:
909-890-0435
Provider Enumeration Date:
07/11/2012

Additional Information

Authorized Official

Authorized Official Last Name:
OCHOA
Authorized Official First Name:
ERICA
Authorized Official Middle Name:
Authorized Official Title or Position:
CHIEF COMPLIANCE OFFICER
Authorized Official Telephone Number:
909-388-0882

Provider Taxonomy Codes

  • Taxonomy code: 261QR0405X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)





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