Basic Information
Provider Information | |||||||||
NPI: | 1457489197 | ||||||||
EntityType: | 2 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: | LASALLE MEDICAL ASSOCIATES | ||||||||
LastName: |   | ||||||||
FirstName: |   | ||||||||
MiddleName: |   | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: |   | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 685 CARNEGIE DRIVE | ||||||||
Address2: | SUITE 230 | ||||||||
City: | SAN BERNARDINO | ||||||||
State: | CA | ||||||||
PostalCode: | 92408 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 9098900407 | ||||||||
FaxNumber: | 9098900575 | ||||||||
Practice Location | |||||||||
Address1: | 31762 MISSION TRAIL | ||||||||
Address2: | SUITE F | ||||||||
City: | LAKE ELSINORE | ||||||||
State: | CA | ||||||||
PostalCode: | 92530 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 9516745686 | ||||||||
FaxNumber: | 9516744707 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 03/02/2007 | ||||||||
LastUpdateDate: | 08/22/2020 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: |   | ||||||||
AuthorizedOfficialLastName: | ARTEAGA | ||||||||
AuthorizedOfficialFirstName: | ALBERT | ||||||||
AuthorizedOfficialMiddleName: | HENRY | ||||||||
AuthorizedOfficialTitleorPosition: | PRESIDENT | ||||||||
AuthorizedOfficialTelephone: | 9098900407 | ||||||||
IsSoleProprietor: |   | ||||||||
IsOrganizationSubpart: | N | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: | MR. | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: | M.D. | ||||||||
NPICertificationDate: |   |
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 | GR0079094 | 05 | CA |   | MEDICAID | 00A382060 | 01 | CA | MEDI-CAL ID NUMBER | OTHER |