Basic Information
| Provider Information | |||||||||
| NPI: | 1275691594 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | JERRY L. PETTIS MEMORIAL VA MEDICAL CENTER | ||||||||
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| Mailing Information | |||||||||
| Address1: | 116 N PLYMOUTH WAY | ||||||||
| Address2: | |||||||||
| City: | SAN BERNARDINO | ||||||||
| State: | CA | ||||||||
| PostalCode: | 924084116 | ||||||||
| 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: | 12/06/2006 | ||||||||
| LastUpdateDate: | 08/22/2020 | ||||||||
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| AuthorizedOfficialLastName: | STORDAHL | ||||||||
| AuthorizedOfficialFirstName: | DEAN | ||||||||
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| AuthorizedOfficialTitleorPosition: | MEDICAL CENTER DIRECTOR | ||||||||
| AuthorizedOfficialTelephone: | 9098257084 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | MR. | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 284300000X | G03312 | LA | Y | Hospitals | Special Hospital |
No ID Information.