Provider Demographics
NPI:1245529619
Name:INLAND EMPIRE MEDICAL NETWORK, INC.
Entity type:Organization
Organization Name:INLAND EMPIRE MEDICAL NETWORK, INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CREDENTIALING
Authorized Official - Prefix:
Authorized Official - First Name:LAURIE
Authorized Official - Middle Name:
Authorized Official - Last Name:MANOS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:909-398-1550
Mailing Address - Street 1:9140 HAVEN AVE
Mailing Address - Street 2:SUITE110
Mailing Address - City:RANCHO CUCAMONGA
Mailing Address - State:CA
Mailing Address - Zip Code:91730-5414
Mailing Address - Country:US
Mailing Address - Phone:909-398-1550
Mailing Address - Fax:909-398-1573
Practice Address - Street 1:790 E BONITA AVE
Practice Address - Street 2:2ND FLOOR
Practice Address - City:POMONA
Practice Address - State:CA
Practice Address - Zip Code:91767-1906
Practice Address - Country:US
Practice Address - Phone:909-447-8585
Practice Address - Fax:909-447-8593
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-04-06
Last Update Date:2011-04-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Multi-Specialty