Provider Demographics
NPI:1316044696
Name:MONTCLAIR EMERGENCY MEDICAL ASSOCIATES
Entity Type:Organization
Organization Name:MONTCLAIR EMERGENCY MEDICAL ASSOCIATES
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DEPARTMENT COORDINATOR
Authorized Official - Prefix:MISS
Authorized Official - First Name:JUSTINE
Authorized Official - Middle Name:
Authorized Official - Last Name:GUEVARA
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:424-241-1546
Mailing Address - Street 1:PO BOX 80456
Mailing Address - Street 2:
Mailing Address - City:CITY OF INDUSTRY
Mailing Address - State:CA
Mailing Address - Zip Code:91716-8402
Mailing Address - Country:US
Mailing Address - Phone:310-379-2134
Mailing Address - Fax:310-379-4856
Practice Address - Street 1:5000 SAN BERNARDINO ST
Practice Address - Street 2:
Practice Address - City:MONTCLAIR
Practice Address - State:CA
Practice Address - Zip Code:91763-2326
Practice Address - Country:US
Practice Address - Phone:909-625-8307
Practice Address - Fax:909-625-8255
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-09-20
Last Update Date:2020-11-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207P00000XAllopathic & Osteopathic PhysiciansEmergency MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAGR0104390Medicaid
CAZZZ04136ZMedicare PIN