Provider Demographics
NPI:1902562416
Name:SOUTHERN INDIAN HEALTH COUNCIL INC
Entity Type:Organization
Organization Name:SOUTHERN INDIAN HEALTH COUNCIL INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:LEAD BILLER
Authorized Official - Prefix:
Authorized Official - First Name:MARIE
Authorized Official - Middle Name:
Authorized Official - Last Name:DIZON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:619-445-1188
Mailing Address - Street 1:8 CRESTWOOD RD
Mailing Address - Street 2:
Mailing Address - City:BOULEVARD
Mailing Address - State:CA
Mailing Address - Zip Code:91905-9725
Mailing Address - Country:US
Mailing Address - Phone:619-445-1188
Mailing Address - Fax:
Practice Address - Street 1:8 CRESTWOOD RD
Practice Address - Street 2:
Practice Address - City:BOULEVARD
Practice Address - State:CA
Practice Address - Zip Code:91905-9725
Practice Address - Country:US
Practice Address - Phone:619-445-1188
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:SOUTHERN INDIAN HEALTH COUNCIL INC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2021-11-10
Last Update Date:2021-11-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QR0401XAmbulatory Health Care FacilitiesClinic/CenterRehabilitation, Comprehensive Outpatient Rehabilitation Facility (CORF)
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAW7576AOtherMEDICARE
CATHP70010FMedicaid