Basic Information
Provider Information | |||||||||
NPI: | 1083865695 | ||||||||
EntityType: | 2 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: | VA LOMA LINDA HEALTHCARE SYSTEM | ||||||||
LastName: |   | ||||||||
FirstName: |   | ||||||||
MiddleName: |   | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: |   | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 25898 LOMAS VERDES ST | ||||||||
Address2: |   | ||||||||
City: | REDLANDS | ||||||||
State: | CA | ||||||||
PostalCode: | 923738404 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 9097968291 | ||||||||
FaxNumber: |   | ||||||||
Practice Location | |||||||||
Address1: | 11201 BENTON ST | ||||||||
Address2: |   | ||||||||
City: | LOMA LINDA | ||||||||
State: | CA | ||||||||
PostalCode: | 923571000 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 9098257084 | ||||||||
FaxNumber: |   | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 10/02/2008 | ||||||||
LastUpdateDate: | 10/02/2008 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: |   | ||||||||
AuthorizedOfficialLastName: | TOMA | ||||||||
AuthorizedOfficialFirstName: | CORNELIA | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: | STAFF NURSE | ||||||||
AuthorizedOfficialTelephone: | 9098257084 | ||||||||
IsSoleProprietor: |   | ||||||||
IsOrganizationSubpart: | N | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: | MRS. | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: | RN | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 275N00000X | 640533 | CA | Y |   | Hospital Units | Medicare Defined Swing Bed Unit |   |
No ID Information.