1396859179 NPI number — COUNTY OF RIVERSIDE

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 1396859179 NPI number — COUNTY OF RIVERSIDE

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
COUNTY OF RIVERSIDE
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:
LAKE ELSINORE FAMILY CARE CENTER
Provider Other Organization Name Type Code:
5
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:
1396859179
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
06/12/2009
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 7849
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
RIVERSIDE
Provider Business Mailing Address State Name:
CA
Provider Business Mailing Address Postal Code:
92513-7849
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
951-358-5222
Provider Business Mailing Address Fax Number:
951-358-5235

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
2499 E LAKESHORE DR
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
LAKE ELSINORE
Provider Business Practice Location Address State Name:
CA
Provider Business Practice Location Address Postal Code:
92530-4446
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
951-471-4200
Provider Business Practice Location Address Fax Number:
951-471-4205
Provider Enumeration Date:
08/18/2006

Additional Information

Authorized Official

Authorized Official Last Name:
BROWN
Authorized Official First Name:
KOEN
Authorized Official Middle Name:
Authorized Official Title or Position:
DEPUTY DIRECTOR II
Authorized Official Telephone Number:
951-358-5222

Provider Taxonomy Codes

  • Taxonomy code: 251K00000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 261QF0400X , with the licence number: 250000542 , registered in the state of CA ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: BCP70724F . This is a "CANCER DETECTION PROGRAM" identifier , issued by the state of ( CA ) . This identifiers is of the category "OTHER".
  • Identifier: FHC70724F , issued by the state of ( CA ) . This identifiers is of the category "MEDICAID".
  • Identifier: HAP70724F . This is a "FAMILY PACT" identifier , issued by the state of ( CA ) . This identifiers is of the category "OTHER".




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