Provider Demographics
NPI:1558658864
Name:EGB HOLDINGS
Entity Type:Organization
Organization Name:EGB HOLDINGS
Other - Org Name:ADVANTAGE HEALTH SYSTEMS
Other - Org Type:Doing Business As
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:
Authorized Official - First Name:EMIL
Authorized Official - Middle Name:
Authorized Official - Last Name:BUNDANG
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:951-686-0003
Mailing Address - Street 1:PO BOX 261485
Mailing Address - Street 2:
Mailing Address - City:SAN DIEGO
Mailing Address - State:CA
Mailing Address - Zip Code:92196-1485
Mailing Address - Country:US
Mailing Address - Phone:951-686-0003
Mailing Address - Fax:951-686-0005
Practice Address - Street 1:4100 LATHAM STREET
Practice Address - Street 2:SUITE D
Practice Address - City:RIVERSIDE
Practice Address - State:CA
Practice Address - Zip Code:92501-1733
Practice Address - Country:US
Practice Address - Phone:951-686-0003
Practice Address - Fax:951-686-0005
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-07-07
Last Update Date:2018-10-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251E00000XAgenciesHome Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA550001894OtherCDPH LICENSE
CA059476Medicare Oscar/Certification