Provider Demographics
NPI:1497881007
Name:INLAND GLAUCOMA SERVICE MEDICAL CORPORATION
Entity Type:Organization
Organization Name:INLAND GLAUCOMA SERVICE MEDICAL CORPORATION
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DOCTOR
Authorized Official - Prefix:DR
Authorized Official - First Name:LESLIE
Authorized Official - Middle Name:ALEXANDER
Authorized Official - Last Name:BRUCE-LYLE
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:909-799-1992
Mailing Address - Street 1:11320 MOUNTAIN VIEW AVE STE B
Mailing Address - Street 2:
Mailing Address - City:LOMA LINDA
Mailing Address - State:CA
Mailing Address - Zip Code:92354-3860
Mailing Address - Country:US
Mailing Address - Phone:909-799-1992
Mailing Address - Fax:909-799-1499
Practice Address - Street 1:11320 MOUNTAIN VIEW AVE STE B
Practice Address - Street 2:
Practice Address - City:LOMA LINDA
Practice Address - State:CA
Practice Address - Zip Code:92354-3860
Practice Address - Country:US
Practice Address - Phone:909-799-1992
Practice Address - Fax:909-799-1499
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-02-26
Last Update Date:2011-02-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA51441207W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207W00000XAllopathic & Osteopathic PhysiciansOphthalmologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAAB331BMedicare PIN
CAAB331AMedicare PIN