Basic Information
Provider Information | |||||||||
NPI: | 1780865519 | ||||||||
EntityType: | 2 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: | EMINENCE HEALTHCARE, INC. | ||||||||
LastName: |   | ||||||||
FirstName: |   | ||||||||
MiddleName: |   | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: |   | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | PO BOX 27707 | ||||||||
Address2: |   | ||||||||
City: | FRESNO | ||||||||
State: | CA | ||||||||
PostalCode: | 937297707 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 5592218100 | ||||||||
FaxNumber: | 5592218101 | ||||||||
Practice Location | |||||||||
Address1: | 1400 ANCHOR AVE | ||||||||
Address2: | RM 10B, 15B, 16, MEDIA CENTER/LIBRARY | ||||||||
City: | ORANGE COVE | ||||||||
State: | CA | ||||||||
PostalCode: | 936462369 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 5592218100 | ||||||||
FaxNumber: | 5592218101 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 11/20/2007 | ||||||||
LastUpdateDate: | 01/28/2015 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: |   | ||||||||
AuthorizedOfficialLastName: | GARZA | ||||||||
AuthorizedOfficialFirstName: | JUAN | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: | COO/PROGRAM DIRECTOR | ||||||||
AuthorizedOfficialTelephone: | 5592218100 | ||||||||
IsSoleProprietor: |   | ||||||||
IsOrganizationSubpart: | N | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: | MR. | ||||||||
AuthorizedOfficialNameSuffix: | II | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
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 |