Basic Information
| Provider Information | |||||||||
| NPI: | 1215226642 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | INLAND EMPIRE MEDICAL NERTWORK, INC. | ||||||||
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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: | 9190 HAVEN AVE | ||||||||
| Address2: | 1ST FLOOR | ||||||||
| City: | RANCHO CUCAMONGA | ||||||||
| State: | CA | ||||||||
| PostalCode: | 917305431 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9095816732 | ||||||||
| FaxNumber: | 9095816737 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 04/06/2011 | ||||||||
| LastUpdateDate: | 04/06/2011 | ||||||||
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| AuthorizedOfficialLastName: | MANOS | ||||||||
| AuthorizedOfficialFirstName: | LAURIE | ||||||||
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| AuthorizedOfficialTitleorPosition: | CREDENTIALING | ||||||||
| AuthorizedOfficialTelephone: | 9093981550 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207N00000X | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Dermatology | 207Q00000X | Y | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Family Medicine |
No ID Information.