Provider Demographics
NPI:1881054997
Name:EMANATE HEALTH MEDICAL GROUP
Entity type:Organization
Organization Name:EMANATE HEALTH MEDICAL GROUP
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:JACQUELINE
Authorized Official - Middle Name:
Authorized Official - Last Name:BRACY
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:626-858-8580
Mailing Address - Street 1:210 W SAN BERNARDINO RD
Mailing Address - Street 2:
Mailing Address - City:COVINA
Mailing Address - State:CA
Mailing Address - Zip Code:91723-1515
Mailing Address - Country:US
Mailing Address - Phone:626-858-8580
Mailing Address - Fax:626-858-8582
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:626-858-8580
Practice Address - Fax:626-858-8582
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-03-02
Last Update Date:2019-07-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA207V00000X
208D00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208D00000XAllopathic & Osteopathic PhysiciansGeneral PracticeGroup - Multi-Specialty
No207V00000XAllopathic & Osteopathic PhysiciansObstetrics & GynecologyGroup - Multi-Specialty