Riverside-San Bernardino County Indian Health, Inc
Organization Active NPI Federally Qualified Health Center (FQHC) · Mountain Center, CA
NPI 1366028086 · NPPES record last updated Sep 16, 2021
Key facts
- NPI
- 1366028086
- Entity type
- Organization (NPI type 2)
- Primary specialty
- Federally Qualified Health Center (FQHC) 261QF0400X
- Legal business name
- RIVERSIDE-SAN BERNARDINO COUNTY INDIAN HEALTH, INC
- Practice address
- 65175 St. Highway 74
Mountain Center, CA 92561-9231 - Phone
- (951) 823-8882
- Fax
- (951) 225-6879
- NPI assigned
- Mar 23, 2021
- Organization subpart
- No
Authorized official
- Name
- William Thomsen
- Title
- Ceo
- Phone
- (909) 864-1097
Other NPIs on the same Medicare enrollment 9
Other NPIs with the same Medicare PAC ID 6
Corporate family (same tax ID) 19
Practitioners 109
-
Sameera Ahmad, OD
-
Margaret Akua Amoo, NURSE PRACTITIONER
-
Craig F Callam, APRN, FNP-BC
-
Daniel R. Crogan, MD
-
John Austin Davis, PSY.D.
-
Jean T Dinh, OD
-
Eric Eschweiler, DNP, RN, FNP-C
-
April Michelle Figueroa, FNP-C
-
Ashley Fonseca-Tweed, FNP-BC
-
Donald L Hamby, D.O.
-
Brian Thomas Haven, DPM
-
Mallory Adele Kennedy, O.D.
-
Arthur Leitzke, M.D.
-
Ebrahim Ahmed Mohamedy, M.D.
-
Pamela Enjema Mokoko, FAMILY NURSE PRACTIT
-
Ngoc Kim Nguyen, RN MSN FNP-BC CMSRN
-
Tracie Michelle Noble, NURSE PRACTITIONER
-
Ruth A Ogot, DNP-C
-
William Howard Park, O.D.
Medicare participation
- Medicare fee-for-service enrollment
- Enrolled (2 enrollments) in TX, CA
Federally qualified health center certification: CCN A01114
- Legal name
- RIVERSIDE-SAN BERNARDINO COUNTY INDIAN HEALTH INC
- Doing business as
- SANTA ROSA INDIAN HEALTH CLINIC
- Certification status
- Active
- Provider type (POS)
- Federally qualified health center
- Participating since
- Sep 7, 2022
- Last certification
- Sep 7, 2022
- Ownership / control type
- For profit – corporation
- Organization structure
- Corporation · Non-profit
- Incorporated
- Apr 3, 1974 in CA
- Enrollment address
- 65175 State Highway 74
Mountain Center, CA 92561-4039
All disclosed owners & managing parties 10
| Name | Role | Since | Share |
|---|---|---|---|
| Veronica E Saul |
Corporate Director |
Jan 7, 2017 | 5% |
| Julie a Arriettaparcero |
Corporate Director |
Jan 7, 2017 | 5% |
| William Thomsen |
Corporate Director |
May 1, 2021 | 100% |
| Vuliet Danial |
W-2 Managing Employee |
Nov 16, 2018 | |
| John M Marcus |
Corporate Director |
Jan 7, 2017 | 5% |
| Desiree Franco |
Corporate Director |
Jan 7, 2017 | 5% |
| Sherri Salgado |
Corporate Director |
Jan 7, 2017 | 5% |
| Teresa L Sanchez |
Corporate Director |
Jan 7, 2017 | 5% |
| Suzanne Lugo |
Corporate Director |
Jan 7, 2017 | 5% |
| Mary E Bussing |
Corporate Director |
Jan 7, 2017 | 5% |
Medicare enrollment records
| Enrollment ID | State | Provider type | PAC ID | Details |
|---|---|---|---|---|
| O20150508001121 | TX | Part B Supplier - Clinic/Group Practice | 4789867805 |
Receives reassigned benefits from 98 practitioners 9 other NPIs on this enrollment This NPI is an additional NPI on the enrollment Practice locations: Thermal, CA; Temecula, CA; San Jacinto, CA; Grand Terrace, CA; Mountain Center, CA; Anza, CA; Barstow, CA; Banning, CA |
| O20220912001768 | CA | Part a Provider - Federally Qualified Health Center (FQHC) | 4789867805 | Practice locations: Mountain Center, CA |
National Provider Directory
- Tax ID family
- Riverside San Bernandin
Locations
2210 E Highland Ave
Ste 200
San Bernardino, CA 92404
Phone (888) 268-0008
Specialties & licenses
| Specialty (taxonomy) | Code | License | State | Primary |
|---|---|---|---|---|
| Federally Qualified Health Center (FQHC) | 261QF0400X | Yes |
Addresses
Primary practice location
65175 St. Highway 74
Mountain Center, CA 92561-9231
Mailing address
11980 Mount Vernon Ave
Grand Terrace, CA 92313-5172
Phone (909) 864-1097
Other names
- Santa Rosa Indian Health Clinic
Other providers in Mountain Center, CA
- Thomas Burton Jackson
- Aexis Aide Mendoza
- Riverside/San Bernardino County Indian Health, Inc.
- Taylor D Stein
- Patricia B Tucker Hoover
All providers in Mountain Center, CA · Federally Qualified Health Center (FQHC) in California
Sources for this page
- NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Record last updated by the provider on Sep 16, 2021. Information in NPPES is self-reported and not verified by CMS.
- NUCC Health Care Provider Taxonomy: specialty names.
- Medicare Fee-For-Service Public Provider Enrollment (CMS/PECOS): enrollments, PAC IDs and benefit reassignments.
- CMS facility enrollments, All Owners and change-of-ownership files: CCNs, owners and managing parties.
- Provider of Services files (CMS): certification status, beds and related CCNs.
- National Provider Directory (CMS): practice roles, locations, licenses, networks and endpoints.