Provider Demographics
NPI:1194971820
Name:FAMILY SERVICE AGENCY OF FONTANA
Entity type:Organization
Organization Name:FAMILY SERVICE AGENCY OF FONTANA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT/CEO
Authorized Official - Prefix:MS
Authorized Official - First Name:CHRISTINE
Authorized Official - Middle Name:LAURA
Authorized Official - Last Name:EDGECOMBE
Authorized Official - Suffix:
Authorized Official - Credentials:MLS/AC
Authorized Official - Phone:909-886-6737
Mailing Address - Street 1:1669 NORTH E STREET
Mailing Address - Street 2:
Mailing Address - City:SAN BERNARDINO
Mailing Address - State:CA
Mailing Address - Zip Code:92405-4405
Mailing Address - Country:US
Mailing Address - Phone:909-886-6737
Mailing Address - Fax:909-881-3871
Practice Address - Street 1:1661 N E ST
Practice Address - Street 2:
Practice Address - City:SAN BERNARDINO
Practice Address - State:CA
Practice Address - Zip Code:92405-4405
Practice Address - Country:US
Practice Address - Phone:909-822-3533
Practice Address - Fax:909-822-3050
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-08-13
Last Update Date:2013-01-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251S00000XAgenciesCommunity/Behavioral Health