Healthcare Provider Details

I. General information

NPI: 1598093262
Provider Name (Legal Business Name): EASTERN MEDICAL CENTER PROFESSIONAL MEDICAL CORPORATION
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/18/2009
Last Update Date: 12/23/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2930 EASTERN AVE
SACRAMENTO CA
95821-4210
US

IV. Provider business mailing address

2930 EASTERN AVE
SACRAMENTO CA
95821-4210
US

V. Phone/Fax

Practice location:
  • Phone: 916-972-8966
  • Fax: 916-972-8916
Mailing address:
  • Phone: 916-972-8966
  • Fax: 916-972-8916

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License NumberA65618
License Number StateCA
# 2
Primary TaxonomyN
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License NumberA83360
License Number StateCA
# 3
Primary TaxonomyN
Taxonomy Code208D00000X
TaxonomyGeneral Practice Physician
License NumberA73749
License Number StateCA

VIII. Authorized Official

Name: DR. LI LI
Title or Position: CEO
Credential: M.D.
Phone: 916-972-8966