Healthcare Provider Details

I. General information

NPI: 1982102539
Provider Name (Legal Business Name): BRUKE TEDLA
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/29/2018
Last Update Date: 11/11/2025
Certification Date: 11/11/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

11324 ANDERSON ST
LOMA LINDA CA
92350-1728
US

IV. Provider business mailing address

2068 ORANGE TREE LN STE 215
REDLANDS CA
92374-4555
US

V. Phone/Fax

Practice location:
  • Phone: 909-558-8590
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207RA0002X
TaxonomyAdult Congenital Heart Disease Physician
License NumberA160609
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: