Provider Demographics
NPI:1316754278
Name:SAN BERNADINO COUNTY SHERIFF'S DEPARTMENT
Entity type:Organization
Organization Name:SAN BERNADINO COUNTY SHERIFF'S DEPARTMENT
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PROVIDER ENROLLMENT MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:JESSICA
Authorized Official - Middle Name:
Authorized Official - Last Name:SIMMONS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:949-445-3342
Mailing Address - Street 1:655 E 3RD ST
Mailing Address - Street 2:
Mailing Address - City:SAN BERNARDINO
Mailing Address - State:CA
Mailing Address - Zip Code:92415-0061
Mailing Address - Country:US
Mailing Address - Phone:909-463-5000
Mailing Address - Fax:
Practice Address - Street 1:9500 ETIWANDA AVE
Practice Address - Street 2:
Practice Address - City:RANCHO CUCAMONGA
Practice Address - State:CA
Practice Address - Zip Code:91739-9679
Practice Address - Country:US
Practice Address - Phone:909-463-5000
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:COUNTY OF SAN BERNARDINO
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2024-12-14
Last Update Date:2025-04-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207P00000XAllopathic & Osteopathic PhysiciansEmergency MedicineGroup - Multi-Specialty