Provider Demographics
NPI:1245680735
Name:FAMILY SERVICE AGENCY OF SAN BERNARDINO
Entity type:Organization
Organization Name:FAMILY SERVICE AGENCY OF SAN BERNARDINO
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:MS
Authorized Official - First Name:PATRICE
Authorized Official - Middle Name:J
Authorized Official - Last Name:CORMICAN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:909-886-6737
Mailing Address - Street 1:1669 N E ST
Mailing Address - Street 2:
Mailing Address - City:SAN BERNARDINO
Mailing Address - State:CA
Mailing Address - Zip Code:92405-4405
Mailing Address - Country:US
Mailing Address - Phone:909-886-6737
Mailing Address - Fax:909-881-3871
Practice Address - Street 1:11424 CHAMBERLAINE WAY
Practice Address - Street 2:SUITE 11-12
Practice Address - City:ADELANTO
Practice Address - State:CA
Practice Address - Zip Code:92301-2869
Practice Address - Country:US
Practice Address - Phone:909-886-6737
Practice Address - Fax:909-881-3871
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:FAMILY SERVICE AGENCY OF SAN BERNARDINO
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2016-06-15
Last Update Date:2016-06-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251S00000XAgenciesCommunity/Behavioral Health