Provider Demographics
NPI:1053878405
Name:SOUTHERN CALIFORNIA EMERGENCY MEDICINE
Entity type:Organization
Organization Name:SOUTHERN CALIFORNIA EMERGENCY MEDICINE
Other - Org Name:
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 1:1181 N MOUNT VERNON AVE
Practice Address - Street 2:
Practice Address - City:COLTON
Practice Address - State:CA
Practice Address - Zip Code:92324-2574
Practice Address - Country:US
Practice Address - Phone:909-335-1900
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:SOUTHERN CALIFORNIA EMERGENCY MEDICINE
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2019-02-21
Last Update Date:2019-02-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QU0200XAmbulatory Health Care FacilitiesClinic/CenterUrgent Care