Basic Information
| Provider Information | |||||||||
| NPI: | 1548398142 | ||||||||
| 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: | 9098900575 | ||||||||
| Practice Location | |||||||||
| Address1: | 1505 W. 17TH STREET | ||||||||
| Address2: | |||||||||
| City: | SAN BERNARDINO | ||||||||
| State: | CA | ||||||||
| PostalCode: | 92411 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9098876494 | ||||||||
| FaxNumber: | 9098876043 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 03/02/2007 | ||||||||
| LastUpdateDate: | 08/23/2016 | ||||||||
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| AuthorizedOfficialLastName: | ARTEAGA | ||||||||
| AuthorizedOfficialFirstName: | ALBERT | ||||||||
| AuthorizedOfficialMiddleName: | H. | ||||||||
| AuthorizedOfficialTitleorPosition: | CEO/OWNER | ||||||||
| AuthorizedOfficialTelephone: | 9098900407 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | MR. | ||||||||
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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 | GR0079091 | 05 | CA | MEDICAID | 00A382060 | 01 | CA | MEDI-CAL ID NUMBER | OTHER |