Provider Demographics
NPI:1255701249
Name:SOUTHERN CALIFORNIA EMERGENCY MEDICINE
Entity type:Organization
Organization Name:SOUTHERN CALIFORNIA EMERGENCY MEDICINE
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:CREDENTIALING MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:JENNIFER
Authorized Official - Middle Name:
Authorized Official - Last Name:BRUNK
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:909-596-6349
Mailing Address - Street 1:1407 FOOTHILL BLVD # 14
Mailing Address - Street 2:
Mailing Address - City:LA VERNE
Mailing Address - State:CA
Mailing Address - Zip Code:91750-3451
Mailing Address - Country:US
Mailing Address - Phone:909-596-6349
Mailing Address - Fax:
Practice Address - Street 1:1295 HAMNER AVE STE C
Practice Address - Street 2:
Practice Address - City:NORCO
Practice Address - State:CA
Practice Address - Zip Code:92860-3161
Practice Address - Country:US
Practice Address - Phone:951-272-6500
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-10-02
Last Update Date:2015-10-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA73011261QU0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QU0200XAmbulatory Health Care FacilitiesClinic/CenterUrgent Care