1275722001 NPI number — EMINENCE HEALTHCARE SERVICES, LLC

Table of Contents

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1275722001 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:
1275722001
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:
1700 ANCHOR AVE
Provider Second Line Business Practice Location Address:
ROOMS 104 & 404
Provider Business Practice Location Address City Name:
ORANGE COVE
Provider Business Practice Location Address State Name:
CA
Provider Business Practice Location Address Postal Code:
93646-2374
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:
10/17/2007

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

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

  • Identifier: 101076 . This is a "MEDI-CAL" identifier , issued by the state of ( CA ) . This identifiers is of the category "OTHER".




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