1730305236 NPI number — EMINENCE HEALTHCARE SERVICES, LLC

Table of content: (NPI 1730305236)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1730305236 NPI number — EMINENCE HEALTHCARE SERVICES, LLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
EMINENCE HEALTHCARE SERVICES, LLC
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:
Provider Other Organization Name Type Code:
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:
1730305236
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
09/21/2017
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 27707
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
FRESNO
Provider Business Mailing Address State Name:
CA
Provider Business Mailing Address Postal Code:
93729-7707
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
559-221-8100
Provider Business Mailing Address Fax Number:
559-221-8101

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
4443 W WELDON AVE
Provider Second Line Business Practice Location Address:
RM E-14
Provider Business Practice Location Address City Name:
FRESNO
Provider Business Practice Location Address State Name:
CA
Provider Business Practice Location Address Postal Code:
93722-5440
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
559-221-8100
Provider Business Practice Location Address Fax Number:
559-221-8101
Provider Enumeration Date:
04/17/2007

Additional Information

Authorized Official

Authorized Official Last Name:
GARZA
Authorized Official First Name:
JUAN
Authorized Official Middle Name:
Authorized Official Title or Position:
CEO/PROGRAM DIRECTOR
Authorized Official Telephone Number:
559-221-8100

Provider Taxonomy Codes

  • Taxonomy code: 261QR0405X , registered in the state of CA ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 261QR0405X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 101076000 . This is a "DRUG MEDI-CAL" identifier , issued by the state of ( CA ) . This identifiers is of the category "OTHER".




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