Basic Information
| Provider Information | |||||||||
| NPI: | 1265673032 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | VA LOMA LINDA HEALTH CARE SYSTEM | ||||||||
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| Mailing Information | |||||||||
| Address1: | 11201 BENTON ST | ||||||||
| Address2: | |||||||||
| City: | LOMA LINDA | ||||||||
| State: | CA | ||||||||
| PostalCode: | 923571000 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9098257084 | ||||||||
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| Practice Location | |||||||||
| Address1: | 11201 BENTON ST | ||||||||
| Address2: | |||||||||
| City: | LOMA LINDA | ||||||||
| State: | CA | ||||||||
| PostalCode: | 923571000 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9098257084 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 03/09/2009 | ||||||||
| LastUpdateDate: | 09/01/2014 | ||||||||
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| AuthorizedOfficialLastName: | ALTOMONTE | ||||||||
| AuthorizedOfficialFirstName: | STEPHANIE | ||||||||
| AuthorizedOfficialMiddleName: | DEANN | ||||||||
| AuthorizedOfficialTitleorPosition: | PSYCHOLOGY TECHNICIAN | ||||||||
| AuthorizedOfficialTelephone: | 9098257084 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | MS. | ||||||||
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| AuthorizedOfficialCredential: | MA, LPC, NCC | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 324500000X | N | Residential Treatment Facilities | Substance Abuse Rehabilitation Facility | 261QR0405X | Y | Ambulatory Health Care Facilities | Clinic/Center | Rehabilitation, Substance Use Disorder |
No ID Information.