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General NPI Number Information
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NPI Number | 1073872610
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Entity Type | Organization
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Legal Business Name | EBTKS MEDICAL CENTER, A PROF CORP.
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Dates
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Enumeration Date | 05/15/2012
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Last Update Date | 04/30/2018
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Provider Practice Location Address
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Address Line | 4515 HALLMARK PKWY
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City | SAN BERNARDINO
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State | CA
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Zip | 92407-1834
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Country | US
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Telephone | 909-648-3551
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Fax |
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Provider Business Mailing Address
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Address Line | 4515 HALLMARK PKWY
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City | SAN BERNARDINO
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State | CA
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Zip | 92407-1834
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Country | US
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Telephone | 909-648-3551
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Fax |
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Authorized Official
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Title or Position | CEO
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Name | MICHAEL JOSEPH TRUDEAU
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Credential | DC
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Telephone | 909-648-3551
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 261QM1300X
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Taxonomy Name | Multi-Specialty Clinic/Center
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License Number |
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License Number State |
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Taxonomy #2
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Taxonomy Code | 261QH0100X
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Taxonomy Name | Health Service Clinic/Center
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License Number | DC18676
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License Number State | CA
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