Basic Information
| Provider Information | |||||||||
| NPI: | 1912230939 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | VA LOMA LINDA HEALTH CARE SYSTEM | ||||||||
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| Mailing Information | |||||||||
| Address1: | 22990 ORANGEWOOD CT | ||||||||
| Address2: | |||||||||
| City: | GRAND TERRACE | ||||||||
| State: | CA | ||||||||
| PostalCode: | 923135549 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9098257084 | ||||||||
| FaxNumber: | 9097773854 | ||||||||
| Practice Location | |||||||||
| Address1: | 11201 BENTON ST | ||||||||
| Address2: | RM#3A-25 | ||||||||
| City: | LOMA LINDA | ||||||||
| State: | CA | ||||||||
| PostalCode: | 923571000 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9098257084 | ||||||||
| FaxNumber: | 9097773854 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 09/09/2009 | ||||||||
| LastUpdateDate: | 09/09/2009 | ||||||||
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| AuthorizedOfficialLastName: | BRADLEY | ||||||||
| AuthorizedOfficialFirstName: | VICKI | ||||||||
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| AuthorizedOfficialTitleorPosition: | CHIEF AUDIOLOGY & SPEECH PATHOLOGY | ||||||||
| AuthorizedOfficialTelephone: | 9098257084 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | DR. | ||||||||
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| AuthorizedOfficialCredential: | AUD | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 282N00000X | 12843 | CA | Y | Hospitals | General Acute Care Hospital |
No ID Information.