MEDICARE: EMINENCE HEALTHCARE, INC.

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

General Provider Information

NPI Number	:	1790174837
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	EMINENCE HEALTHCARE, INC.

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	:

Provider Business Practice Location Address
First Line	:	33087 ROAD 228
Second Line	:	ROOM 23
City	:	NORTH FORK
State	:	CA
Zip	:	93643-9695
Country	:	US
Telephone Number	:	559-877-2215
Fax Number	:

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

Provider Enumeration Date	:	01/13/2015
Last Update Date	:	07/01/2015

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