Provider Demographics
NPI:1407871965
Name:EMANATE HEALTH MEDICAL CENTER
Entity Type:Organization
Organization Name:EMANATE HEALTH MEDICAL CENTER
Other - Org Name:INTERCOMMUNITY SCREENING CENTER
Other - Org Type:Doing Business As
Authorized Official - Title/Position:EXECUTIVE VP/CFO
Authorized Official - Prefix:
Authorized Official - First Name:ROGER
Authorized Official - Middle Name:
Authorized Official - Last Name:SHARMA
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:626-938-7595
Mailing Address - Street 1:PO BOX 840145
Mailing Address - Street 2:
Mailing Address - City:LOS ANGELES
Mailing Address - State:CA
Mailing Address - Zip Code:90084-0145
Mailing Address - Country:US
Mailing Address - Phone:626-331-7331
Mailing Address - Fax:
Practice Address - Street 1:315 N 3RD AVE STE 203
Practice Address - Street 2:
Practice Address - City:COVINA
Practice Address - State:CA
Practice Address - Zip Code:91723-1915
Practice Address - Country:US
Practice Address - Phone:626-331-7331
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:EMANATE HEALTH
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2006-07-13
Last Update Date:2020-10-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes174400000XOther Service ProvidersSpecialistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA171413OtherFDA APPROVAL#
CA16266Medicare PIN
CA171413OtherFDA APPROVAL#