Basic Information
| Provider Information | |||||||||
| NPI: | 1023398468 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | LASALLE MEDICAL ASSOCIATES | ||||||||
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| Mailing Information | |||||||||
| Address1: | 685 CARNEGIE DR | ||||||||
| Address2: | SUITE 230 | ||||||||
| City: | SAN BERNARDINO | ||||||||
| State: | CA | ||||||||
| PostalCode: | 924083502 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9098900407 | ||||||||
| FaxNumber: | 9098900575 | ||||||||
| Practice Location | |||||||||
| Address1: | 685 CARNEGIE DR | ||||||||
| Address2: | SUITE 230 | ||||||||
| City: | SAN BERNARDINO | ||||||||
| State: | CA | ||||||||
| PostalCode: | 924083502 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9098900407 | ||||||||
| FaxNumber: | 9098900575 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/17/2011 | ||||||||
| LastUpdateDate: | 08/17/2011 | ||||||||
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| AuthorizedOfficialLastName: | ARTEAGA | ||||||||
| AuthorizedOfficialFirstName: | ALBERT | ||||||||
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| AuthorizedOfficialTitleorPosition: | PRESIDENT / OWNER | ||||||||
| AuthorizedOfficialTelephone: | 9098900407 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | DR. | ||||||||
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| AuthorizedOfficialCredential: | M.D. | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 305R00000X | 202469 | CA | Y | Managed Care Organizations | Preferred Provider Organization |
No ID Information.