Basic Information
| Provider Information | |||||||||
| NPI: | 1023206729 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | LOMA LINDA MGMT | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1011 17TH ST | ||||||||
| Address2: | |||||||||
| City: | BAKERSFIELD | ||||||||
| State: | CA | ||||||||
| PostalCode: | 933014703 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6613224085 | ||||||||
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| Practice Location | |||||||||
| Address1: | 1011 17TH ST | ||||||||
| Address2: | |||||||||
| City: | BAKERSFIELD | ||||||||
| State: | CA | ||||||||
| PostalCode: | 933014703 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6613224085 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/09/2007 | ||||||||
| LastUpdateDate: | 10/09/2007 | ||||||||
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| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | MOHAN | ||||||||
| AuthorizedOfficialFirstName: | SAMIR | ||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | PRESIDENT | ||||||||
| AuthorizedOfficialTelephone: | 6613224085 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 261QA0600X | CA | Y | Ambulatory Health Care Facilities | Clinic/Center | Adult Day Care |
ID Information
| ID | Type | State | Issuer | Description | ADU70429F | 05 | CA | MEDICAID |