Basic Information
Provider Information | |||||||||
NPI: | 1043538010 | ||||||||
EntityType: | 2 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: | INLAND EMPIRE MEDICAL NETWORK,INC. | ||||||||
LastName: |   | ||||||||
FirstName: |   | ||||||||
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Mailing Information | |||||||||
Address1: | 9140 HAVEN AVE | ||||||||
Address2: | SUITE 110 | ||||||||
City: | RANCHO CUCAMONGA | ||||||||
State: | CA | ||||||||
PostalCode: | 917305414 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 9093981550 | ||||||||
FaxNumber: | 9093981573 | ||||||||
Practice Location | |||||||||
Address1: | 585 N MOUNTAIN AVE | ||||||||
Address2: | SUITE C | ||||||||
City: | UPLAND | ||||||||
State: | CA | ||||||||
PostalCode: | 917868516 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 9099818599 | ||||||||
FaxNumber: | 9099815441 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 05/14/2010 | ||||||||
LastUpdateDate: | 04/06/2011 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
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ProviderGenderCode: |   | ||||||||
AuthorizedOfficialLastName: | MANOS | ||||||||
AuthorizedOfficialFirstName: | LAURIE | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: | CREDENTIALING | ||||||||
AuthorizedOfficialTelephone: | 9093981550 | ||||||||
IsSoleProprietor: |   | ||||||||
IsOrganizationSubpart: | N | ||||||||
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Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207RE0101X |   |   | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Internal Medicine | Endocrinology, Diabetes & Metabolism | 363LF0000X |   |   | N | 193200000X MULTI-SPECIALTY GROUP | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Family | 207Q00000X |   |   | Y | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Family Medicine |   |
No ID Information.