Healthcare Provider Details

I. General information

NPI: 1275691594
Provider Name (Legal Business Name): JERRY L. PETTIS MEMORIAL VA MEDICAL CENTER
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/06/2006
Last Update Date: 08/22/2020
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

11201 BENTON ST
LOMA LINDA CA
92357-1000
US

IV. Provider business mailing address

116 N PLYMOUTH WAY
SAN BERNARDINO CA
92408-4116
US

V. Phone/Fax

Practice location:
  • Phone: 909-825-7084
  • Fax:
Mailing address:
  • Phone: 909-825-7084
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code284300000X
TaxonomySpecial Hospital
License NumberG03312
License Number StateLA

VIII. Authorized Official

Name: MR. DEAN STORDAHL
Title or Position: MEDICAL CENTER DIRECTOR
Credential:
Phone: 909-825-7084