Provider Demographics
NPI:1417161621
Name:SALVADOR E LASALA MD A MEDICAL CORPORATION
Entity Type:Organization
Organization Name:SALVADOR E LASALA MD A MEDICAL CORPORATION
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:SALVADOR
Authorized Official - Middle Name:E
Authorized Official - Last Name:LASALA
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:909-886-3100
Mailing Address - Street 1:399 E HIGHLAND AVE
Mailing Address - Street 2:STE 214
Mailing Address - City:SAN BERNARDINO
Mailing Address - State:CA
Mailing Address - Zip Code:92404-3816
Mailing Address - Country:US
Mailing Address - Phone:909-886-3100
Mailing Address - Fax:909-886-4100
Practice Address - Street 1:399 E HIGHLAND AVE
Practice Address - Street 2:STE 214
Practice Address - City:SAN BERNARDINO
Practice Address - State:CA
Practice Address - Zip Code:92404-3816
Practice Address - Country:US
Practice Address - Phone:909-886-3100
Practice Address - Fax:909-886-4100
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-05-09
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA52616103TP2701X, 171M00000X, 2084P0804X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Not Answered103TP2701XBehavioral Health & Social Service ProvidersPsychologistGroup PsychotherapyGroup - Multi-Specialty
Not Answered171M00000XOther Service ProvidersCase Manager/Care CoordinatorGroup - Multi-Specialty
Not Answered2084P0804XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyChild & Adolescent PsychiatryGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
G90005Medicare UPIN
CAWA52616AMedicare ID - Type Unspecified