Healthcare Provider Details

I. General information

NPI: 1699721514
Provider Name (Legal Business Name): LOMA LINDA UNIVERSITY RADIATION MEDICINE
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/25/2006
Last Update Date: 08/22/2020
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

11234 ANDERSON ST
LOMA LINDA CA
92354
US

IV. Provider business mailing address

PO BOX 30969
LOS ANGELES CA
90030-0969
US

V. Phone/Fax

Practice location:
  • Phone: 909-558-3012
  • Fax: 909-558-3905
Mailing address:
  • Phone: 909-558-3012
  • Fax: 909-558-3292

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2085R0001X
TaxonomyRadiation Oncology Physician
License Number
License Number State

VIII. Authorized Official

Name: JERRY SLATER
Title or Position: PRESIDENT
Credential: MD
Phone: 909-558-3014