NPIMap

Organization Active NPI

Riverside-San Bernardino County Indian Health, Inc

Doing business as Santa Rosa Indian Health Clinic

  • Federally Qualified Health Center (FQHC)
  • Mountain Center, CA
National Provider Identifier
1366028086
Registry record updated Sep 16, 2021
On this page

Key facts

NPPES NPI Registry
Primary specialty
Federally Qualified Health Center (FQHC)Taxonomy code 261QF0400X
Legal business name
RIVERSIDE-SAN BERNARDINO COUNTY INDIAN HEALTH, INC
Doing business as
Santa Rosa Indian Health Clinic
Practice address
65175 St. Highway 74
Mountain Center, CA 92561-9231
Phone
(951) 823-8882
Fax
(951) 225-6879
NPI assigned
Mar 23, 2021
Last updated
Sep 16, 2021By the provider in NPPES
Organization subpart
No

NPPES NPI Registry

Updated by the provider on Sep 16, 2021

Registry information is reported by the provider to CMS and is not verified. About this source

Authorized official

Name
William Thomsen
Title
Ceo
Phone
(909) 864-1097

Specialties & licenses 1

Specialty (taxonomy)CodeLicenseStatePrimary
Federally Qualified Health Center (FQHC) 261QF0400X Primary

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 1

  • Santa Rosa Indian Health Clinic Doing business as

Medicare participation

Medicare enrollment files
Medicare fee-for-service enrollment
Enrolled in TX, CA2 enrollments

Enrollment records 2

Enrollment IDStateProvider typePAC IDDetails
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

NPI to CCN mapping 1

The Medicare certification numbers (CCNs) connected to NPI 1366028086. Details of each certification follow.

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
CorporationNon-profit
Incorporated
Apr 3, 1974 in CA
Enrollment address
65175 State Highway 74
Mountain Center, CA 92561-4039

Other NPIs with the same Medicare PAC ID 6

NPIs whose Medicare enrollments share a PECOS associate control ID (the same enrolled entity).

Other NPIs on the same Medicare enrollment 9

NPIs listed together on one Medicare enrollment, typically parts of the same organization.

National Provider Directory

National Provider Directory
Tax ID family
Rsbcihi20 organizations share this tax ID, including this one

Other organizations with this tax ID 19

Organizations that report the same tax identification number in the National Provider Directory.

View all 19

Locations

53000 Cahuilla Rd
Anza, CA 92539
Phone (909) 864-1097

2210 E Highland Ave
Ste 200
San Bernardino, CA 92404
Phone (888) 268-0008

Ownership & related parties

All disclosed owners & managing parties 10

As disclosed on the Medicare enrollment (CMS All Owners files). Individuals include officers, directors and managing employees, who may not hold ownership.

NameRoleSinceShare
Veronica E Saul Individual Corporate DirectorBoard Member Jan 7, 2017 5%
Julie a Arriettaparcero Individual Corporate DirectorBoard Member Jan 7, 2017 5%
William Thomsen Individual Corporate DirectorChief Executive Officer May 1, 2021 100%
Vuliet Danial Individual W-2 Managing EmployeeContract Specialist Nov 16, 2018
John M Marcus Individual Corporate DirectorBoard Member Jan 7, 2017 5%
Desiree Franco Individual Corporate DirectorBoard Member Jan 7, 2017 5%
Sherri Salgado Individual Corporate DirectorBoard Member Jan 7, 2017 5%
Teresa L Sanchez Individual Corporate DirectorBoard Member Jan 7, 2017 5%
Suzanne Lugo Individual Corporate DirectorBoard Member Jan 7, 2017 5%
Mary E Bussing Individual Corporate DirectorBoard Member Jan 7, 2017 5%

Practitioners & affiliated clinicians

Practitioners 105

Individual providers connected to this organization through Medicare benefit reassignment, Care Compare group membership or National Provider Directory roles, and the practitioner matching its NPPES authorized official.

View all 105

NPI Registry JSON

The complete NPPES record for this NPI in the NPI Registry API format.

{
    "created_epoch": "1616457600000",
    "enumeration_type": "NPI-2",
    "last_updated_epoch": "1631750400000",
    "number": "1366028086",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "11980 MOUNT VERNON AVE",
            "city": "GRAND TERRACE",
            "state": "CA",
            "postal_code": "923135172",
            "telephone_number": "909-864-1097",
            "fax_number": "951-225-6879"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "65175 ST. HIGHWAY 74",
            "city": "MOUNTAIN CENTER",
            "state": "CA",
            "postal_code": "925619231",
            "telephone_number": "951-823-8882",
            "fax_number": "951-225-6879"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "organization_name": "RIVERSIDE-SAN BERNARDINO COUNTY INDIAN HEALTH, INC",
        "organizational_subpart": "NO",
        "enumeration_date": "2021-03-23",
        "last_updated": "2021-09-16",
        "certification_date": "2021-09-16",
        "status": "A",
        "authorized_official_last_name": "THOMSEN",
        "authorized_official_first_name": "WILLIAM",
        "authorized_official_title_or_position": "CEO",
        "authorized_official_telephone_number": "909-864-1097"
    },
    "taxonomies": [
        {
            "code": "261QF0400X",
            "taxonomy_group": "",
            "desc": "Clinic/Center, Federally Qualified Health Center (FQHC)",
            "state": null,
            "license": null,
            "primary": true
        }
    ],
    "identifiers": [],
    "endpoints": [],
    "other_names": [
        {
            "organization_name": "Santa Rosa Indian Health Clinic",
            "code": "3",
            "type": "Doing Business As"
        },
        {
            "organization_name": "Santa Rosa Indian Health Clinic",
            "code": "3",
            "type": "Doing Business As"
        }
    ]
}

Other providers in Mountain Center, CA

Sources for this page

Verify at the official NPI Registry.