Basic Information
| Provider Information | |||||||||
| NPI: | 1922054493 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | LOMA LINDA UNIV FAMILY MEDICAL GROUP INC. | ||||||||
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| Mailing Information | |||||||||
| Address1: | FILE NUMBER 54701 | ||||||||
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| City: | LOS ANGELES | ||||||||
| State: | CA | ||||||||
| PostalCode: | 900744701 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9095583111 | ||||||||
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| Practice Location | |||||||||
| Address1: | 25455 BARTON ROAD | ||||||||
| Address2: | STE 204B | ||||||||
| City: | LOMA LINDA | ||||||||
| State: | CA | ||||||||
| PostalCode: | 92354 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9095586600 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 05/26/2006 | ||||||||
| LastUpdateDate: | 10/08/2008 | ||||||||
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| AuthorizedOfficialLastName: | TESTERMAN | ||||||||
| AuthorizedOfficialFirstName: | JOHN | ||||||||
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| AuthorizedOfficialTitleorPosition: | PRESIDENT LLU FAMILY MEDICAL GROUP | ||||||||
| AuthorizedOfficialTelephone: | 9095586600 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialCredential: | MD | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207Q00000X | Y | 193400000X SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Family Medicine |
ID Information
| ID | Type | State | Issuer | Description | GR0000450 | 05 | CA | MEDICAID |