Provider Demographics
NPI:1992760417
Name:EMMANUEL MEDICAL PROVIDERS
Entity type:Organization
Organization Name:EMMANUEL MEDICAL PROVIDERS
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:DR
Authorized Official - First Name:DEE BENG
Authorized Official - Middle Name:K
Authorized Official - Last Name:LIM
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:909-447-5554
Mailing Address - Street 1:9675 MONTE VISTA AVE
Mailing Address - Street 2:STE B
Mailing Address - City:MONTCLAIR
Mailing Address - State:CA
Mailing Address - Zip Code:91763-2213
Mailing Address - Country:US
Mailing Address - Phone:909-447-5554
Mailing Address - Fax:909-447-5582
Practice Address - Street 1:9675 MONTE VISTA AVE
Practice Address - Street 2:STE B
Practice Address - City:MONTCLAIR
Practice Address - State:CA
Practice Address - Zip Code:91763-2213
Practice Address - Country:US
Practice Address - Phone:909-447-5554
Practice Address - Fax:909-447-5582
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-04-18
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAC39980207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA00C399801Medicaid
CA00C399801Medicaid