Provider Demographics
NPI:1447388251
Name:LASALLE MEDICAL ASSOCIATES
Entity Type:Organization
Organization Name:LASALLE MEDICAL ASSOCIATES
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO/OWNER
Authorized Official - Prefix:
Authorized Official - First Name:ALBERT
Authorized Official - Middle Name:H
Authorized Official - Last Name:ARTEAGA
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:909-890-0407
Mailing Address - Street 1:1855 W REDLANDS BLVD
Mailing Address - Street 2:2ND FLOOR
Mailing Address - City:REDLANDS
Mailing Address - State:CA
Mailing Address - Zip Code:92373-3145
Mailing Address - Country:US
Mailing Address - Phone:909-890-0407
Mailing Address - Fax:909-890-0575
Practice Address - Street 1:565 N. MT. VERNON AVE.
Practice Address - Street 2:
Practice Address - City:SAN BERNARDINO
Practice Address - State:CA
Practice Address - Zip Code:92411-2661
Practice Address - Country:US
Practice Address - Phone:909-884-9091
Practice Address - Fax:909-383-7013
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-03-01
Last Update Date:2016-08-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
261QM1300X
CAA38206261QM1300X
CAA31849261QM1300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QM1300XAmbulatory Health Care FacilitiesClinic/CenterMulti-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAP00014299OtherRR MEDICARE PIN
CA00A382060OtherMEDI-CAL ID NUMBER
CAGR0079095Medicaid
CAP00014299OtherRAILROAD MEDICARE UPIN
CA00A382060OtherMEDI-CAL ID NUMBER
CAZZZ16166ZMedicare UPIN