Basic Information
| Provider Information | |||||||||
| NPI: | 1720384548 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | EMPIRE SPECIALISTS INCORPORATED | ||||||||
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| Mailing Information | |||||||||
| Address1: | 2115 COMPTON AVE | ||||||||
| Address2: | SUITE 104 | ||||||||
| City: | CORONA | ||||||||
| State: | CA | ||||||||
| PostalCode: | 928817272 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6267988600 | ||||||||
| FaxNumber: | 6267988842 | ||||||||
| Practice Location | |||||||||
| Address1: | 82013 DR CARREON BLVD | ||||||||
| Address2: | SUITE G | ||||||||
| City: | INDIO | ||||||||
| State: | CA | ||||||||
| PostalCode: | 922014832 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9512807888 | ||||||||
| FaxNumber: | 9513729014 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 01/27/2011 | ||||||||
| LastUpdateDate: | 11/26/2012 | ||||||||
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| AuthorizedOfficialLastName: | JAYASINGHE | ||||||||
| AuthorizedOfficialFirstName: | WALTER | ||||||||
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| AuthorizedOfficialTitleorPosition: | CEO | ||||||||
| AuthorizedOfficialTelephone: | 9512807700 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | DR. | ||||||||
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| AuthorizedOfficialCredential: | M.D. | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207N00000X | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Dermatology | 2081P2900X | Y | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Physical Medicine & Rehabilitation | Pain Medicine |
No ID Information.