Provider Demographics
NPI:1528172541
Name:SAN BERNARDINO MOUNTAINS COMMUNITY HOSPITAL DISTRICT
Entity type:Organization
Organization Name:SAN BERNARDINO MOUNTAINS COMMUNITY HOSPITAL DISTRICT
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:CFO
Authorized Official - Prefix:MS
Authorized Official - First Name:YVONNE
Authorized Official - Middle Name:D
Authorized Official - Last Name:WAGGENER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:909-336-3651
Mailing Address - Street 1:PO BOX 70
Mailing Address - Street 2:
Mailing Address - City:LAKE ARROWHEAD
Mailing Address - State:CA
Mailing Address - Zip Code:92352-0070
Mailing Address - Country:US
Mailing Address - Phone:909-336-9715
Mailing Address - Fax:909-336-5751
Practice Address - Street 1:29099 HOSPITAL ROAD
Practice Address - Street 2:#200
Practice Address - City:LAKE ARROWHEAD
Practice Address - State:CA
Practice Address - Zip Code:92352
Practice Address - Country:US
Practice Address - Phone:909-336-9715
Practice Address - Fax:909-336-5751
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:SAN BERNARDINO MOUNTAINS COMMUNITY HOSPITALS DISTRICT
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2006-08-18
Last Update Date:2023-08-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CARHM18535F261QR1300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QR1300XAmbulatory Health Care FacilitiesClinic/CenterRural Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
O58535OtherMEDICARE
CAHAP18535FMedicaid
CARHM18535FMedicaid
CAHAP18535FMedicaid
O58535OtherMEDICARE
CAO51312Medicare ID - Type Unspecified
058535Medicare Oscar/Certification