Provider Demographics
NPI:1841417300
Name:RIVERSIDE-SAN BERNARDINO COUNTY INDIAN HEALTH, INC.
Entity type:Organization
Organization Name:RIVERSIDE-SAN BERNARDINO COUNTY INDIAN HEALTH, INC.
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:MR
Authorized Official - First Name:LINWOOD
Authorized Official - Middle Name:J
Authorized Official - Last Name:KILLAM
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:951-849-4761
Mailing Address - Street 1:11555 POTRERO RD
Mailing Address - Street 2:
Mailing Address - City:BANNING
Mailing Address - State:CA
Mailing Address - Zip Code:92220-6946
Mailing Address - Country:US
Mailing Address - Phone:951-849-4761
Mailing Address - Fax:951-849-5612
Practice Address - Street 1:11555 POTRERO RD
Practice Address - Street 2:
Practice Address - City:BANNING
Practice Address - State:CA
Practice Address - Zip Code:92220-6946
Practice Address - Country:US
Practice Address - Phone:951-849-4761
Practice Address - Fax:951-849-5612
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-04-19
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QF0400XAmbulatory Health Care FacilitiesClinic/CenterFederally Qualified Health Center (FQHC)
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAEAPC03854FMedicaid