Healthcare Provider Details

I. General information

NPI: 1104270008
Provider Name (Legal Business Name): LAUREL GUTHRIE
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/17/2016
Last Update Date: 07/24/2023
Certification Date: 07/24/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

11175 CAMPUS ST STE 21111
LOMA LINDA CA
92350-1700
US

IV. Provider business mailing address

11175 CAMPUS ST STE 21111
LOMA LINDA CA
92350-1700
US

V. Phone/Fax

Practice location:
  • Phone: 909-558-5939
  • Fax:
Mailing address:
  • Phone: 909-558-5939
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number StateNULL
# 2
Primary TaxonomyN
Taxonomy Code208600000X
TaxonomySurgery Physician
License Number151036
License Number StateCA
# 3
Primary TaxonomyY
Taxonomy Code2086X0206X
TaxonomySurgical Oncology Physician
License Number151036
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: