Provider Demographics
NPI:1982762977
Name:LH SELF MEDICAL SERVICES PC
Entity Type:Organization
Organization Name:LH SELF MEDICAL SERVICES PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:LEWIS
Authorized Official - Middle Name:H
Authorized Official - Last Name:SELF
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:702-530-7769
Mailing Address - Street 1:315 S COAST HIGHWAY 101 # U14
Mailing Address - Street 2:
Mailing Address - City:ENCINITAS
Mailing Address - State:CA
Mailing Address - Zip Code:92024-3543
Mailing Address - Country:US
Mailing Address - Phone:702-530-7769
Mailing Address - Fax:888-858-1403
Practice Address - Street 1:1415 ROSS AVE
Practice Address - Street 2:
Practice Address - City:EL CENTRO
Practice Address - State:CA
Practice Address - Zip Code:92243
Practice Address - Country:US
Practice Address - Phone:702-530-7769
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-12-04
Last Update Date:2019-08-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NV7570207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NV002019796Medicaid
NVF23601Medicare UPIN