Healthcare Provider Details

I. General information

NPI: 1417161621
Provider Name (Legal Business Name): SALVADOR E LASALA MD A MEDICAL CORPORATION
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/09/2007
Last Update Date: 09/11/2025
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

399 E HIGHLAND AVE STE 214
SAN BERNARDINO CA
92404-3816
US

IV. Provider business mailing address

399 E HIGHLAND AVE STE 214
SAN BERNARDINO CA
92404-3816
US

V. Phone/Fax

Practice location:
  • Phone: 909-886-3100
  • Fax: 909-886-4100
Mailing address:
  • Phone: 909-886-3100
  • Fax: 909-886-4100

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103TP2701X
TaxonomyGroup Psychotherapy Psychologist
License NumberA52616
License Number StateCA
# 2
Primary TaxonomyN
Taxonomy Code171M00000X
TaxonomyCase Manager/Care Coordinator
License NumberA52616
License Number StateCA
# 3
Primary TaxonomyN
Taxonomy Code2084P0804X
TaxonomyChild & Adolescent Psychiatry Physician
License NumberA52616
License Number StateCA

VIII. Authorized Official

Name: DR. SALVADOR E LASALA
Title or Position: PRESIDENT
Credential: MD
Phone: 909-886-3100