1962602839 NPI number — PACIFIC CLINICS

Table of content: (NPI 1962602839)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1962602839 NPI number — PACIFIC CLINICS

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
PACIFIC CLINICS
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:
PACIFIC CLINICS MAGNOLIA PARK
Provider Other Organization Name Type Code:
5
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:
1962602839
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
02/03/2012
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
800 S SANTA ANITA AVE
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
ARCADIA
Provider Business Mailing Address State Name:
CA
Provider Business Mailing Address Postal Code:
91006-6853
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
626-254-5000
Provider Business Mailing Address Fax Number:
626-294-1077

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
827 N AVON ST
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
BURBANK
Provider Business Practice Location Address State Name:
CA
Provider Business Practice Location Address Postal Code:
91505-2916
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
818-558-4677
Provider Business Practice Location Address Fax Number:
818-848-8137
Provider Enumeration Date:
07/19/2007

Additional Information

Authorized Official

Authorized Official Last Name:
MANDEL
Authorized Official First Name:
SUSAN
Authorized Official Middle Name:
Authorized Official Title or Position:
PRESIDENT/CEO
Authorized Official Telephone Number:
626-254-5000

Provider Taxonomy Codes

  • Taxonomy code: 251S00000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 7703 , issued by the state of ( CA ) . This identifiers is of the category "MEDICAID".




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