=====================================================
General NPI Number Information
=====================================================
NPI Number | 1083865695
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | VA LOMA LINDA HEALTHCARE SYSTEM
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 10/02/2008
-----------------------------------------------------
Last Update Date | 10/02/2008
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 11201 BENTON ST
-----------------------------------------------------
City | LOMA LINDA
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 92357-1000
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 909-825-7084
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 25898 LOMAS VERDES ST
-----------------------------------------------------
City | REDLANDS
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 92373-8404
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 909-796-8291
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | STAFF NURSE
-----------------------------------------------------
Name | MRS. CORNELIA TOMA
-----------------------------------------------------
Credential | RN
-----------------------------------------------------
Telephone | 909-825-7084
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 275N00000X
-----------------------------------------------------
Taxonomy Name | Medicare Defined Swing Bed Hospital Unit
-----------------------------------------------------
License Number | 640533
-----------------------------------------------------
License Number State | CA
-----------------------------------------------------