Healthcare Provider Details

I. General information

NPI: 1326582743
Provider Name (Legal Business Name): EMANATE HEALTH MEDICAL GROUP
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/05/2016
Last Update Date: 09/06/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

440 W FOOTHILL BLVD
GLENDORA CA
91741-3361
US

IV. Provider business mailing address

1325 N GRAND AVE SUITE 300
COVINA CA
91724-4044
US

V. Phone/Fax

Practice location:
  • Phone: 626-963-9402
  • Fax: 626-623-7244
Mailing address:
  • Phone: 626-732-3159
  • Fax: 626-732-3194

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number
License Number StateCA

VIII. Authorized Official

Name: MRS. CHRISTINE H HADDAD
Title or Position: ASSISTANT DIRECTOR OF AMBULATORY BU
Credential:
Phone: 626-732-3159