Provider Demographics
NPI:1699976597
Name:CHILDREN'S CRISIS RESPONSE TEAM MORONGO BASIN
Entity type:Organization
Organization Name:CHILDREN'S CRISIS RESPONSE TEAM MORONGO BASIN
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:INFORMATION TECHNOLOGY MANAGER
Authorized Official - Prefix:MR
Authorized Official - First Name:MICHAEL
Authorized Official - Middle Name:J
Authorized Official - Last Name:DAY
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:909-388-0570
Mailing Address - Street 1:268 W. HOSPITALITY LANE
Mailing Address - Street 2:SUITE 400
Mailing Address - City:SAN BERNARDINO
Mailing Address - State:CA
Mailing Address - Zip Code:92415-0026
Mailing Address - Country:US
Mailing Address - Phone:909-382-3080
Mailing Address - Fax:909-382-3105
Practice Address - Street 1:56357 PIMA TRAIL
Practice Address - Street 2:
Practice Address - City:YUCCA VALLEY
Practice Address - State:CA
Practice Address - Zip Code:92284
Practice Address - Country:US
Practice Address - Phone:909-382-3080
Practice Address - Fax:909-382-3105
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:DEPARTMENT OF BEHAVIORAL HEALTH, SAN BERNARDINO COUNTY, CA
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2007-05-29
Last Update Date:2007-07-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAZZZ74743Z261QM0855X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QM0855XAmbulatory Health Care FacilitiesClinic/CenterAdolescent and Children Mental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA3600036DGOtherMEDICAL PROVIDER NUMBER