Basic Information
| Provider Information | |||||||||
| NPI: | 1508848730 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | EMMANUEL HEALTH CARE | ||||||||
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| Mailing Information | |||||||||
| Address1: | 805 W ARROW HWY | ||||||||
| Address2: | |||||||||
| City: | GLENDORA | ||||||||
| State: | CA | ||||||||
| PostalCode: | 91740 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6263310781 | ||||||||
| FaxNumber: | 6263328835 | ||||||||
| Practice Location | |||||||||
| Address1: | 805 W ARROW HWY | ||||||||
| Address2: | |||||||||
| City: | GLENDORA | ||||||||
| State: | CA | ||||||||
| PostalCode: | 91740 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6263310781 | ||||||||
| FaxNumber: | 6263328835 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 11/15/2005 | ||||||||
| LastUpdateDate: | 08/22/2020 | ||||||||
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| AuthorizedOfficialLastName: | MASON | ||||||||
| AuthorizedOfficialFirstName: | KAREN | ||||||||
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| AuthorizedOfficialTitleorPosition: | EXECUTIVE DIRECTOR | ||||||||
| AuthorizedOfficialTelephone: | 6263310781 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 314000000X | CA | Y | Nursing & Custodial Care Facilities | Skilled Nursing Facility |
ID Information
| ID | Type | State | Issuer | Description | ZZT06079J | 05 | CA | MEDICAID |