=====================================================
General NPI Number Information
=====================================================
NPI Number | 1417161621
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | SALVADOR E LASALA MD A MEDICAL CORPORATION
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 05/09/2007
-----------------------------------------------------
Last Update Date | 09/11/2025
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 399 E HIGHLAND AVE STE 214
-----------------------------------------------------
City | SAN BERNARDINO
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 92404-3816
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 909-886-3100
-----------------------------------------------------
Fax | 909-886-4100
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 399 E HIGHLAND AVE STE 214
-----------------------------------------------------
City | SAN BERNARDINO
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 92404-3816
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 909-886-3100
-----------------------------------------------------
Fax | 909-886-4100
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | PRESIDENT
-----------------------------------------------------
Name | DR. SALVADOR E LASALA
-----------------------------------------------------
Credential | MD
-----------------------------------------------------
Telephone | 909-886-3100
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 171M00000X
-----------------------------------------------------
Taxonomy Name | Case Manager/Care Coordinator
-----------------------------------------------------
License Number | A52616
-----------------------------------------------------
License Number State | CA
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 2084P0804X
-----------------------------------------------------
Taxonomy Name | Child & Adolescent Psychiatry Physician
-----------------------------------------------------
License Number | A52616
-----------------------------------------------------
License Number State | CA
-----------------------------------------------------
Taxonomy #3
-----------------------------------------------------
Taxonomy Code | 103TP2701X
-----------------------------------------------------
Taxonomy Name | Group Psychotherapy Psychologist
-----------------------------------------------------
License Number | A52616
-----------------------------------------------------
License Number State | CA
-----------------------------------------------------