Provider Demographics
NPI:1922354349
Name:LOMA LINDA UNIVERSITY
Entity Type:Organization
Organization Name:LOMA LINDA UNIVERSITY
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PROVIDER ENROLLMENT REP
Authorized Official - Prefix:
Authorized Official - First Name:LISA
Authorized Official - Middle Name:
Authorized Official - Last Name:WOLTER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:909-651-4352
Mailing Address - Street 1:FILE # 54701
Mailing Address - Street 2:
Mailing Address - City:LOS ANGELES
Mailing Address - State:CA
Mailing Address - Zip Code:90074-4701
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1686 BARTON RD
Practice Address - Street 2:
Practice Address - City:REDLANDS
Practice Address - State:CA
Practice Address - Zip Code:92373-1488
Practice Address - Country:US
Practice Address - Phone:909-558-9551
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:LOMA LINDA UNIVERSITY HEALTH SYSTEMS
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2012-08-03
Last Update Date:2012-08-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologistGroup - Multi-Specialty
No104100000XBehavioral Health & Social Service ProvidersSocial WorkerGroup - Multi-Specialty
No106H00000XBehavioral Health & Social Service ProvidersMarriage & Family TherapistGroup - Multi-Specialty