Provider Demographics
NPI:1174678734
Name:EASTLAND MEDICAL GROUP, INC.
Entity Type:Organization
Organization Name:EASTLAND MEDICAL GROUP, INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CHIEF OF OPERATIONS
Authorized Official - Prefix:
Authorized Official - First Name:LAURA
Authorized Official - Middle Name:
Authorized Official - Last Name:LONGLEY
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:626-960-8614
Mailing Address - Street 1:751 N TODD AVE
Mailing Address - Street 2:
Mailing Address - City:AZUSA
Mailing Address - State:CA
Mailing Address - Zip Code:91702-2244
Mailing Address - Country:US
Mailing Address - Phone:626-960-8614
Mailing Address - Fax:626-960-8624
Practice Address - Street 1:751 N TODD AVE
Practice Address - Street 2:
Practice Address - City:AZUSA
Practice Address - State:CA
Practice Address - Zip Code:91702-2244
Practice Address - Country:US
Practice Address - Phone:626-960-8614
Practice Address - Fax:626-960-8624
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-01-24
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes302R00000XManaged Care OrganizationsHealth Maintenance Organization