MEDICARE: EMMANUEL MEDICAL PROVIDERS

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	207Q00000X	Family Medicine Physician	C39980	CA

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1992760417
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	EMMANUEL MEDICAL PROVIDERS

Provider Business Mailing Address
First Line	:	9675 MONTE VISTA AVE
Second Line	:	STE B
City	:	MONTCLAIR
State	:	CA
Zip	:	91763-2213
Country	:	US
Telephone Number	:	909-447-5554
Fax Number	:	909-447-5582

Provider Business Practice Location Address
First Line	:	9675 MONTE VISTA AVE
Second Line	:	STE B
City	:	MONTCLAIR
State	:	CA
Zip	:	91763-2213
Country	:	US
Telephone Number	:	909-447-5554
Fax Number	:	909-447-5582

Authorized Official
Title or Position	:	CEO
Name	:	DR. DEE BENG K LIM
Credential	:	MD
Telephone Number	:	909-447-5554

Provider Enumeration Date	:	04/18/2006
Last Update Date	:	08/22/2020

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