Provider Demographics
NPI:1144517863
Name:MT. VERNON COMMUNITY HEALTH CENTER
Entity type:Organization
Organization Name:MT. VERNON COMMUNITY HEALTH CENTER
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT/CEO
Authorized Official - Prefix:
Authorized Official - First Name:RUZAN
Authorized Official - Middle Name:
Authorized Official - Last Name:GEVORKYAN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:909-586-6271
Mailing Address - Street 1:1655 N MOUNT VERNON AVE
Mailing Address - Street 2:SUITE C
Mailing Address - City:SAN BERNARDINO
Mailing Address - State:CA
Mailing Address - Zip Code:92411-1427
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1655 N MOUNT VERNON AVE
Practice Address - Street 2:SUITE C
Practice Address - City:SAN BERNARDINO
Practice Address - State:CA
Practice Address - Zip Code:92411-1427
Practice Address - Country:US
Practice Address - Phone:909-586-6271
Practice Address - Fax:888-777-0807
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-07-01
Last Update Date:2011-07-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA261QP2300X, 261QC1500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QC1500XAmbulatory Health Care FacilitiesClinic/CenterCommunity Health
No261QP2300XAmbulatory Health Care FacilitiesClinic/CenterPrimary Care