Basic Information
| Provider Information | |||||||||
| NPI: | 1497701312 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | LOMA LINDA UNIVERSITY RADIATION MEDICINE | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 30969 | ||||||||
| Address2: | |||||||||
| City: | LOS ANGELES | ||||||||
| State: | CA | ||||||||
| PostalCode: | 900300969 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9095583014 | ||||||||
| FaxNumber: | 9095583292 | ||||||||
| Practice Location | |||||||||
| Address1: | 27990 SHERMAN DRIVE | ||||||||
| Address2: | |||||||||
| City: | SUN CITY | ||||||||
| State: | CA | ||||||||
| PostalCode: | 92381 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9516721931 | ||||||||
| FaxNumber: | 9095583905 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/25/2006 | ||||||||
| LastUpdateDate: | 08/22/2020 | ||||||||
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| AuthorizedOfficialLastName: | SLATER | ||||||||
| AuthorizedOfficialFirstName: | JERRY | ||||||||
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| AuthorizedOfficialTitleorPosition: | PRESIDENT LLU RADIATION MEDICINE | ||||||||
| AuthorizedOfficialTelephone: | 9095583014 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 2085R0001X | Y | 193400000X SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Radiology | Radiation Oncology |
ID Information
| ID | Type | State | Issuer | Description | GR0063622 | 05 | CA | MEDICAID |