Basic Information
| Provider Information | |||||||||
| NPI: | 1063441293 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | EMANATE HEALTH MEDICAL CENTER | ||||||||
| LastName: | |||||||||
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| OtherOrganizationName: | CITRUS VALLEY MEDICAL CENTER INC. | ||||||||
| OtherOrganizationType: | 4 | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 840147 | ||||||||
| Address2: | |||||||||
| City: | LOS ANGELES | ||||||||
| State: | CA | ||||||||
| PostalCode: | 900840147 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6267323100 | ||||||||
| FaxNumber: | 6267323195 | ||||||||
| Practice Location | |||||||||
| Address1: | 1115 S SUNSET AVE | ||||||||
| Address2: | |||||||||
| City: | WEST COVINA | ||||||||
| State: | CA | ||||||||
| PostalCode: | 917903940 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6269624011 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 07/01/2006 | ||||||||
| LastUpdateDate: | 10/27/2020 | ||||||||
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| AuthorizedOfficialLastName: | SHARMA | ||||||||
| AuthorizedOfficialFirstName: | ROGER | ||||||||
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| AuthorizedOfficialTitleorPosition: | EXECUTIVE VP/CFO | ||||||||
| AuthorizedOfficialTelephone: | 6269387595 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | Y | ||||||||
| ParentOrganizationLBN: | EMANATE HEALTH | ||||||||
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| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | 10/27/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 282N00000X | Y | Hospitals | General Acute Care Hospital |
ID Information
| ID | Type | State | Issuer | Description | ZZT40369F | 05 | CA | MEDICAID | ZZZA1939Z | 01 | CA | BLUE SHIELD CA | OTHER | ZZT30369F | 05 | CA | MEDICAID | 209 | 01 | CA | BLUE CROSS SO CAL | OTHER | HSC30369F | 05 | CA | MEDICAID |