Provider Demographics
NPI:1619394228
Name:LOMA LINDA OBSTETRICS & GYNECOLOGY
Entity Type:Organization
Organization Name:LOMA LINDA OBSTETRICS & GYNECOLOGY
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:MRS
Authorized Official - First Name:DANIELLE
Authorized Official - Middle Name:CA
Authorized Official - Last Name:SAWYER MACKNET
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:909-478-7700
Mailing Address - Street 1:25805 BARTON RD STE 107
Mailing Address - Street 2:
Mailing Address - City:LOMA LINDA
Mailing Address - State:CA
Mailing Address - Zip Code:92354-3890
Mailing Address - Country:US
Mailing Address - Phone:909-478-7700
Mailing Address - Fax:909-478-7705
Practice Address - Street 1:25805 BARTON RD STE 107
Practice Address - Street 2:
Practice Address - City:LOMA LINDA
Practice Address - State:CA
Practice Address - Zip Code:92354-3890
Practice Address - Country:US
Practice Address - Phone:909-478-7700
Practice Address - Fax:909-478-7705
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-03-20
Last Update Date:2014-03-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA91409305R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes305R00000XManaged Care OrganizationsPreferred Provider Organization
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAEW529AMedicaid