Basic Information
| Provider Information | |||||||||
| NPI: | 1760651962 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | EMINENCE HEALTHCARE, INC. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 7170 N. FINANCIAL DRIVE | ||||||||
| Address2: | SUITE 135 | ||||||||
| City: | FRESNO | ||||||||
| State: | CA | ||||||||
| PostalCode: | 937202978 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5592218100 | ||||||||
| FaxNumber: | 5592218101 | ||||||||
| Practice Location | |||||||||
| Address1: | 259 W SHERWOOD AVE | ||||||||
| Address2: | |||||||||
| City: | MC FARLAND | ||||||||
| State: | CA | ||||||||
| PostalCode: | 932501519 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5592218100 | ||||||||
| FaxNumber: | 5592218101 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 02/21/2008 | ||||||||
| LastUpdateDate: | 03/01/2011 | ||||||||
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| AuthorizedOfficialLastName: | ANDRADE | ||||||||
| AuthorizedOfficialFirstName: | DONNIE | ||||||||
| AuthorizedOfficialMiddleName: | JOSEPH | ||||||||
| AuthorizedOfficialTitleorPosition: | CEO | ||||||||
| AuthorizedOfficialTelephone: | 5592218100 | ||||||||
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| IsOrganizationSubpart: | Y | ||||||||
| ParentOrganizationLBN: | EMINENCE HEALTHCARE, INC. | ||||||||
| AuthorizedOfficialNamePrefix: | MR. | ||||||||
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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 | MEDI-CAL | OTHER |