Provider Demographics
NPI:1740214808
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:DEPT# 0147
Mailing Address - Street 2:
Mailing Address - City:LOS ANGELES
Mailing Address - State:CA
Mailing Address - Zip Code:90084-0147
Mailing Address - Country:US
Mailing Address - Phone:626-814-0333
Mailing Address - Fax:
Practice Address - Street 1:1115 S SUNSET AVE
Practice Address - Street 2:
Practice Address - City:WEST COVINA
Practice Address - State:CA
Practice Address - Zip Code:91790-3940
Practice Address - Country:US
Practice Address - Phone:626-962-4011
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:EMANATE HEALTH
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2006-07-11
Last Update Date:2020-10-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes314000000XNursing & Custodial Care FacilitiesSkilled Nursing Facility
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAZZZA1939ZOtherBLUE SHIELD CA
CA209OtherBLUE CROSS SO CA
CALTC55556FMedicaid
CA209OtherBLUE CROSS SO CA
CA209OtherBLUE CROSS SO CA