=====================================================
General NPI Number Information
=====================================================
NPI Number | 1255701249
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | SOUTHERN CALIFORNIA EMERGENCY MEDICINE
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 10/02/2015
-----------------------------------------------------
Last Update Date | 10/06/2015
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1295 HAMNER AVE STE C
-----------------------------------------------------
City | NORCO
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 92860-3161
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 951-272-6500
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 1407 FOOTHILL BLVD # 14
-----------------------------------------------------
City | LA VERNE
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 91750-3451
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 909-596-6349
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | CREDENTIALING MANAGER
-----------------------------------------------------
Name | JENNIFER BRUNK
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 909-596-6349
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 261QU0200X
-----------------------------------------------------
Taxonomy Name | Urgent Care Clinic/Center
-----------------------------------------------------
License Number | A73011
-----------------------------------------------------
License Number State | CA
-----------------------------------------------------