Healthcare Provider Details

I. General information

NPI: 1821744178
Provider Name (Legal Business Name): JASON BOMBALES LASALA NP
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 02/25/2022
Last Update Date: 07/19/2022
Certification Date: 07/19/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1225 W 190TH ST STE 280
GARDENA CA
90248-4305
US

IV. Provider business mailing address

1225 W 190TH ST STE 280
GARDENA CA
90248-4305
US

V. Phone/Fax

Practice location:
  • Phone: 310-515-8113
  • Fax: 310-538-2102
Mailing address:
  • Phone: 310-515-8113
  • Fax: 310-538-2102

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LP0808X
TaxonomyPsychiatric/Mental Health Nurse Practitioner
License Number95018499
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: