1093240004 NPI number — EMANATE HEALTH IMAGING

Table of content: (NPI 1093240004)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1093240004 NPI number — EMANATE HEALTH IMAGING

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
EMANATE HEALTH IMAGING
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
CITRUS DIAGNOSTIC IMAGING CORP
Provider Other Organization Name Type Code:
4
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1093240004
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
07/11/2019
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
210 W. SAN BERNARDINO ROAD
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
COVINA
Provider Business Mailing Address State Name:
CA
Provider Business Mailing Address Postal Code:
91723-1515
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
626-732-3159
Provider Business Mailing Address Fax Number:
626-732-3194

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
828 S GRAND AVE STE 104
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
GLENDORA
Provider Business Practice Location Address State Name:
CA
Provider Business Practice Location Address Postal Code:
91740
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
626-963-2057
Provider Business Practice Location Address Fax Number:
626-963-4298
Provider Enumeration Date:
04/27/2017

Additional Information

Authorized Official

Authorized Official Last Name:
UNDERWOOD
Authorized Official First Name:
DAVID
Authorized Official Middle Name:
J
Authorized Official Title or Position:
PRESIDENT
Authorized Official Telephone Number:
951-236-8371

Provider Taxonomy Codes

  • Taxonomy code: 2085R0202X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)





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