Provider Demographics
NPI:1992721161
Name:PRIME HEALTHCARE SERVICES - MONTCLAIR, LLC
Entity type:Organization
Organization Name:PRIME HEALTHCARE SERVICES - MONTCLAIR, LLC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:CHIEF COMPLINANCE COUNSEL
Authorized Official - Prefix:MR
Authorized Official - First Name:CHRISTOPHER
Authorized Official - Middle Name:
Authorized Official - Last Name:DOAN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:909-235-4307
Mailing Address - Street 1:16850 BEAR VALLEY RD
Mailing Address - Street 2:
Mailing Address - City:VICTORVILLE
Mailing Address - State:CA
Mailing Address - Zip Code:92395-5794
Mailing Address - Country:US
Mailing Address - Phone:760-241-8222
Mailing Address - Fax:760-241-8220
Practice Address - Street 1:5000 SAN BERNARDINO ST
Practice Address - Street 2:
Practice Address - City:MONTCLAIR
Practice Address - State:CA
Practice Address - Zip Code:91763-2326
Practice Address - Country:US
Practice Address - Phone:909-625-4111
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-07-14
Last Update Date:2017-06-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes282N00000XHospitalsGeneral Acute Care Hospital
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA050758Medicare Oscar/Certification