Basic Information
| Provider Information | |||||||||
| NPI: | 1316075062 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | LASALLE MEDICAL ASSOCIATES | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1855 W REDLANDS BLVD | ||||||||
| Address2: | 2ND FLOOR | ||||||||
| City: | REDLANDS | ||||||||
| State: | CA | ||||||||
| PostalCode: | 923733145 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9098900407 | ||||||||
| FaxNumber: | 9098904597 | ||||||||
| Practice Location | |||||||||
| Address1: | 16455 MAIN STREET | ||||||||
| Address2: | SUITE 1 | ||||||||
| City: | HESPERIA | ||||||||
| State: | CA | ||||||||
| PostalCode: | 92345 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7609472161 | ||||||||
| FaxNumber: | 7609473673 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 03/02/2007 | ||||||||
| LastUpdateDate: | 08/23/2016 | ||||||||
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| AuthorizedOfficialLastName: | ATEAGA | ||||||||
| AuthorizedOfficialFirstName: | ALBERT | ||||||||
| AuthorizedOfficialMiddleName: | H. | ||||||||
| AuthorizedOfficialTitleorPosition: | CEO/OWNER | ||||||||
| AuthorizedOfficialTelephone: | 9098900407 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialCredential: | M.D. | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 261QM1300X | Y | Ambulatory Health Care Facilities | Clinic/Center | Multi-Specialty |
ID Information
| ID | Type | State | Issuer | Description | GR0079092 | 05 | CA | MEDICAID | 00A382060 | 01 | CA | MEDI-CAL ID NUMBER | OTHER | P00226162 | 01 | CA | RAILROAD MEDICARE UPIN | OTHER |