Healthcare Provider Details

I. General information

NPI: 1043538010
Provider Name (Legal Business Name): INLAND EMPIRE MEDICAL NETWORK,INC.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/14/2010
Last Update Date: 04/06/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

585 N MOUNTAIN AVE SUITE C
UPLAND CA
91786-8516
US

IV. Provider business mailing address

9140 HAVEN AVE SUITE 110
RANCHO CUCAMONGA CA
91730-5414
US

V. Phone/Fax

Practice location:
  • Phone: 909-981-8599
  • Fax: 909-981-5441
Mailing address:
  • Phone: 909-398-1550
  • Fax: 909-398-1573

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code207RE0101X
TaxonomyEndocrinology, Diabetes & Metabolism Physician
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number
License Number State

VIII. Authorized Official

Name: LAURIE MANOS
Title or Position: CREDENTIALING
Credential:
Phone: 909-398-1550