Provider Demographics
NPI:1669507620
Name:EMANATE HEALTH MEDICAL CENTER
Entity Type:Organization
Organization Name:EMANATE HEALTH MEDICAL CENTER
Other - Org Name:CITRUS VALLEY MEDICAL CENTER INC
Other - Org Type:Former Legal Business Name
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 1:210 W SAN BERNARDINO RD
Mailing Address - Street 2:P.O. BOX 6108
Mailing Address - City:COVINA
Mailing Address - State:CA
Mailing Address - Zip Code:91723-1515
Mailing Address - Country:US
Mailing Address - Phone:626-915-6273
Mailing Address - Fax:626-859-5887
Practice Address - Street 1:210 W SAN BERNARDINO RD
Practice Address - Street 2:
Practice Address - City:COVINA
Practice Address - State:CA
Practice Address - Zip Code:91723-1515
Practice Address - Country:US
Practice Address - Phone:626-915-6273
Practice Address - Fax:626-859-5887
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:EMANATE HEALTH
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2007-02-22
Last Update Date:2020-10-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
174400000X, 282N00000X
CAHSP43961282N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes282N00000XHospitalsGeneral Acute Care HospitalGroup - Single Specialty
No174400000XOther Service ProvidersSpecialistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAZZT40382GMedicaid
CA050382Medicare ID - Type UnspecifiedMEDICARE