Provider Demographics
NPI:1457489197
Name:LASALLE MEDICAL ASSOCIATES
Entity Type:Organization
Organization Name:LASALLE MEDICAL ASSOCIATES
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:MR
Authorized Official - First Name:ALBERT
Authorized Official - Middle Name:HENRY
Authorized Official - Last Name:ARTEAGA
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:909-890-0407
Mailing Address - Street 1:685 CARNEGIE DRIVE
Mailing Address - Street 2:SUITE 230
Mailing Address - City:SAN BERNARDINO
Mailing Address - State:CA
Mailing Address - Zip Code:92408
Mailing Address - Country:US
Mailing Address - Phone:909-890-0407
Mailing Address - Fax:909-890-0575
Practice Address - Street 1:31762 MISSION TRAIL
Practice Address - Street 2:SUITE F
Practice Address - City:LAKE ELSINORE
Practice Address - State:CA
Practice Address - Zip Code:92530
Practice Address - Country:US
Practice Address - Phone:951-674-5686
Practice Address - Fax:951-674-4707
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-03-02
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QM1300XAmbulatory Health Care FacilitiesClinic/CenterMulti-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAGR0079094Medicaid
CA00A382060OtherMEDI-CAL ID NUMBER