Basic Information
| Provider Information | |||||||||
| NPI: | 1306035100 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | EMINENCE HEALTHCARE, INC. | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 27707 | ||||||||
| Address2: | |||||||||
| City: | FRESNO | ||||||||
| State: | CA | ||||||||
| PostalCode: | 937297707 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5592218100 | ||||||||
| FaxNumber: | 5592218101 | ||||||||
| Practice Location | |||||||||
| Address1: | 2269 SYLVIA ST | ||||||||
| Address2: | ROOM 11 | ||||||||
| City: | SELMA | ||||||||
| State: | CA | ||||||||
| PostalCode: | 936623436 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5592218100 | ||||||||
| FaxNumber: | 5592218101 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/17/2007 | ||||||||
| LastUpdateDate: | 01/28/2015 | ||||||||
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| AuthorizedOfficialLastName: | GARZA | ||||||||
| AuthorizedOfficialFirstName: | JUAN | ||||||||
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| AuthorizedOfficialTitleorPosition: | COO/PROGRAM DIRECTOR | ||||||||
| AuthorizedOfficialTelephone: | 5592218100 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | MR. | ||||||||
| AuthorizedOfficialNameSuffix: | II | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 261QR0405X | Y | Ambulatory Health Care Facilities | Clinic/Center | Rehabilitation, Substance Use Disorder |
ID Information
| ID | Type | State | Issuer | Description | 101076 | 01 | CA | DRUG MEDI-CAL | OTHER |