Provider Demographics
NPI:1871549477
Name:LOMA LINDA UNIV UROLOGY MEDICAL GROUP INC
Entity type:Organization
Organization Name:LOMA LINDA UNIV UROLOGY MEDICAL GROUP INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT LLU UROLOGY MEDICAL GROUP
Authorized Official - Prefix:
Authorized Official - First Name:HERBERT
Authorized Official - Middle Name:
Authorized Official - Last Name:RUCKLE
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:909-558-2830
Mailing Address - Street 1:FILE NUMBER 54701
Mailing Address - Street 2:
Mailing Address - City:LOS ANGELES
Mailing Address - State:CA
Mailing Address - Zip Code:90074-4701
Mailing Address - Country:US
Mailing Address - Phone:909-558-3111
Mailing Address - Fax:909-558-3905
Practice Address - Street 1:26520 CACTUS AVE
Practice Address - Street 2:
Practice Address - City:MORENO VALLEY
Practice Address - State:CA
Practice Address - Zip Code:92555
Practice Address - Country:US
Practice Address - Phone:909-558-2830
Practice Address - Fax:909-558-3905
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-05-25
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208800000XAllopathic & Osteopathic PhysiciansUrologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAGR0056042Medicaid
CAZZZ26208ZMedicare ID - Type Unspecified