Provider Demographics
NPI:1992723803
Name:EMERGENCY MEDICAL OFFICE, INC.
Entity type:Organization
Organization Name:EMERGENCY MEDICAL OFFICE, INC.
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:ADMINISTRATOR
Authorized Official - Prefix:
Authorized Official - First Name:ROBERT
Authorized Official - Middle Name:ANDREW
Authorized Official - Last Name:NELSON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:951-769-0079
Mailing Address - Street 1:264 N HIGHLAND SPRINGS AVE STE 4
Mailing Address - Street 2:
Mailing Address - City:BANNING
Mailing Address - State:CA
Mailing Address - Zip Code:92220-3082
Mailing Address - Country:US
Mailing Address - Phone:951-769-0079
Mailing Address - Fax:
Practice Address - Street 1:264 N HIGHLAND SPRINGS AVE STE 5A
Practice Address - Street 2:
Practice Address - City:BANNING
Practice Address - State:CA
Practice Address - Zip Code:92220-3083
Practice Address - Country:US
Practice Address - Phone:951-769-0079
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:EMERGENCY MEDICAL OFFICE, INC.
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2006-07-18
Last Update Date:2018-06-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
207Q00000X
CA261QP2000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Multi-Specialty
No261QP2000XAmbulatory Health Care FacilitiesClinic/CenterPhysical TherapyGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAGR0068300Medicaid
CAGR0068300Medicaid
CAZZZ00963ZMedicare PIN