Provider Demographics
NPI:1841448701
Name:JAMES R LAROSE DPM A PROFESSIONAL CORP
Entity type:Organization
Organization Name:JAMES R LAROSE DPM A PROFESSIONAL CORP
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:JAMES
Authorized Official - Middle Name:R
Authorized Official - Last Name:LAROSE
Authorized Official - Suffix:
Authorized Official - Credentials:DPM
Authorized Official - Phone:909-985-2555
Mailing Address - Street 1:1060 N 13TH AVENUE
Mailing Address - Street 2:
Mailing Address - City:UPLAND
Mailing Address - State:CA
Mailing Address - Zip Code:91786-3785
Mailing Address - Country:US
Mailing Address - Phone:909-985-2555
Mailing Address - Fax:909-985-0068
Practice Address - Street 1:1060 N 13TH AVENUE
Practice Address - Street 2:
Practice Address - City:UPLAND
Practice Address - State:CA
Practice Address - Zip Code:91786-3785
Practice Address - Country:US
Practice Address - Phone:909-985-2555
Practice Address - Fax:909-985-0068
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-09-04
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA305R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes305R00000XManaged Care OrganizationsPreferred Provider Organization
Provider Identifiers
StateIdentifier IDID TypeIssuer
CADS9089OtherMEDICARE RAILROAD
CA6501520001Medicare NSC
CA000E14670Medicare PIN
CADS9089OtherMEDICARE RAILROAD