MEDICARE: EMINENCE HEALTHCARE SERVICES, LLC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	261QR0405X	Substance Use Disorder Rehabilitation Clinic/Center

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	106202	OTHER	CA	MEDI-CAL

General Provider Information

NPI Number	:	1700038130
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	EMINENCE HEALTHCARE SERVICES, LLC

Provider Business Mailing Address
First Line	:	PO BOX 27707
Second Line	:
City	:	FRESNO
State	:	CA
Zip	:	93729-7707
Country	:	US
Telephone Number	:	559-221-8100
Fax Number	:	559-221-8101

Provider Business Practice Location Address
First Line	:	4055 N BRYAN AVE
Second Line	:
City	:	FRESNO
State	:	CA
Zip	:	93723-9426
Country	:	US
Telephone Number	:	559-221-8100
Fax Number	:	559-221-8101

Authorized Official
Title or Position	:	CEO/PROGRAM DIRECTOR
Name	:	MR. JUAN GARZA II
Credential	:
Telephone Number	:	559-221-8100

Provider Enumeration Date	:	10/16/2008
Last Update Date	:	09/21/2017

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