1003995101 NPI number — EMG

Table of content: (NPI 1003995101)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1003995101 NPI number — EMG

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
EMG
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:
1003995101
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
06/20/2008
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
10225 AUSTIN DR
Provider Second Line Business Mailing Address:
STE #103
Provider Business Mailing Address City Name:
SPRING VALLEY
Provider Business Mailing Address State Name:
CA
Provider Business Mailing Address Postal Code:
91978-1500
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
619-660-6719
Provider Business Mailing Address Fax Number:
619-660-5934

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
10225 AUSTIN DR
Provider Second Line Business Practice Location Address:
STE #103
Provider Business Practice Location Address City Name:
SPRING VALLEY
Provider Business Practice Location Address State Name:
CA
Provider Business Practice Location Address Postal Code:
91978-1500
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
619-660-6719
Provider Business Practice Location Address Fax Number:
619-660-5934
Provider Enumeration Date:
11/02/2006

Additional Information

Authorized Official

Authorized Official Last Name:
WINEGAR
Authorized Official First Name:
TERRY
Authorized Official Middle Name:
Authorized Official Title or Position:
MEDICAL DIRECTOR
Authorized Official Telephone Number:
619-444-7454

Provider Taxonomy Codes

  • Taxonomy code: 207Q00000X , with the licence number:  16585 , registered in the state of CA ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: W11716 . This is a "MEDICARE CROUP #" identifier . This identifiers is of the category "OTHER".




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