Basic Information
| Provider Information | |||||||||
| NPI: | 1316044696 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | MONTCLAIR EMERGENCY MEDICAL ASSOCIATES | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 80456 | ||||||||
| Address2: | |||||||||
| City: | CITY OF INDUSTRY | ||||||||
| State: | CA | ||||||||
| PostalCode: | 917168402 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3103792134 | ||||||||
| FaxNumber: | 3103794856 | ||||||||
| Practice Location | |||||||||
| Address1: | 5000 SAN BERNARDINO ST | ||||||||
| Address2: | |||||||||
| City: | MONTCLAIR | ||||||||
| State: | CA | ||||||||
| PostalCode: | 917632326 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9096258307 | ||||||||
| FaxNumber: | 9096258255 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 09/20/2006 | ||||||||
| LastUpdateDate: | 11/09/2020 | ||||||||
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| AuthorizedOfficialLastName: | GUEVARA | ||||||||
| AuthorizedOfficialFirstName: | JUSTINE | ||||||||
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| AuthorizedOfficialTitleorPosition: | DEPARTMENT COORDINATOR | ||||||||
| AuthorizedOfficialTelephone: | 4242411546 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | MISS | ||||||||
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| NPICertificationDate: | 11/09/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207P00000X | Y | 193400000X SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Emergency Medicine |
ID Information
| ID | Type | State | Issuer | Description | GR0104390 | 05 | CA | MEDICAID |