1386625465 NPI number — PACIFIC INFUSION CARE INC

Table of content: (NPI 1386625465)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1386625465 NPI number — PACIFIC INFUSION CARE INC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
PACIFIC INFUSION CARE INC
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1386625465
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
08/22/2020
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
11860 KEMPER RD
Provider Second Line Business Mailing Address:
#4
Provider Business Mailing Address City Name:
AUBURN
Provider Business Mailing Address State Name:
CA
Provider Business Mailing Address Postal Code:
95603
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
530-823-7413
Provider Business Mailing Address Fax Number:
530-823-6798

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
11860 KEMPER RD
Provider Second Line Business Practice Location Address:
# 4
Provider Business Practice Location Address City Name:
AUBURN
Provider Business Practice Location Address State Name:
CA
Provider Business Practice Location Address Postal Code:
95603
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
530-823-7413
Provider Business Practice Location Address Fax Number:
530-823-6798
Provider Enumeration Date:
11/07/2005

Additional Information

			
		

Authorized Official

Authorized Official Last Name:
DURTSCHI
Authorized Official First Name:
STEPHEN
Authorized Official Middle Name:
RAY
Authorized Official Title or Position:
PRES
Authorized Official Telephone Number:
530-823-7413

Provider Taxonomy Codes

  • Taxonomy code: 332B00000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "X" .
  • Taxonomy code: 333600000X , with the licence number: PHY46211 , registered in the state of CA ; information, associated with the NPI states the following Primary Taxonomy Switch: "X" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: PHY462110 , issued by the state of ( CA ) . This identifiers is of the category "MEDICAID".