Provider Demographics
NPI:1326582743
Name:EMANATE HEALTH MEDICAL GROUP
Entity Type:Organization
Organization Name:EMANATE HEALTH MEDICAL GROUP
Other - Org Name:FOOTHILL FAMILY PRACTICE
Other - Org Type:Doing Business As
Authorized Official - Title/Position:ASSISTANT DIRECTOR OF AMBULATORY BU
Authorized Official - Prefix:MRS
Authorized Official - First Name:CHRISTINE
Authorized Official - Middle Name:H
Authorized Official - Last Name:HADDAD
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:626-732-3159
Mailing Address - Street 1:1325 N GRAND AVE
Mailing Address - Street 2:SUITE 300
Mailing Address - City:COVINA
Mailing Address - State:CA
Mailing Address - Zip Code:91724-4044
Mailing Address - Country:US
Mailing Address - Phone:626-732-3159
Mailing Address - Fax:626-732-3194
Practice Address - Street 1:440 W FOOTHILL BLVD
Practice Address - Street 2:
Practice Address - City:GLENDORA
Practice Address - State:CA
Practice Address - Zip Code:91741-3361
Practice Address - Country:US
Practice Address - Phone:626-963-9402
Practice Address - Fax:626-623-7244
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-12-05
Last Update Date:2019-09-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty