Provider Demographics
NPI:1497701312
Name:LOMA LINDA UNIVERSITY RADIATION MEDICINE
Entity Type:Organization
Organization Name:LOMA LINDA UNIVERSITY RADIATION MEDICINE
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT LLU RADIATION MEDICINE
Authorized Official - Prefix:
Authorized Official - First Name:JERRY
Authorized Official - Middle Name:
Authorized Official - Last Name:SLATER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:909-558-3014
Mailing Address - Street 1:PO BOX 30969
Mailing Address - Street 2:
Mailing Address - City:LOS ANGELES
Mailing Address - State:CA
Mailing Address - Zip Code:90030-0969
Mailing Address - Country:US
Mailing Address - Phone:909-558-3014
Mailing Address - Fax:909-558-3292
Practice Address - Street 1:27990 SHERMAN DRIVE
Practice Address - Street 2:
Practice Address - City:SUN CITY
Practice Address - State:CA
Practice Address - Zip Code:92381
Practice Address - Country:US
Practice Address - Phone:951-672-1931
Practice Address - Fax:909-558-3905
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-05-25
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2085R0001XAllopathic & Osteopathic PhysiciansRadiologyRadiation OncologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAGR0063622Medicaid
CAZZZ00688ZMedicare ID - Type Unspecified