1013458975 NPI number — PACIFICA COSMETIC SURGERY CENTER, A MEDICAL CORP

Table of content: (NPI 1013458975)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1013458975 NPI number — PACIFICA COSMETIC SURGERY CENTER, A MEDICAL CORP

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
PACIFICA COSMETIC SURGERY CENTER, A MEDICAL CORP
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:
1013458975
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
03/13/2017
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
280 NEWPORT CENTER DR
Provider Second Line Business Mailing Address:
SUITE 120
Provider Business Mailing Address City Name:
NEWPORT BEACH
Provider Business Mailing Address State Name:
CA
Provider Business Mailing Address Postal Code:
92660-7526
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
949-640-9570
Provider Business Mailing Address Fax Number:
949-640-9569

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
280 NEWPORT CENTER DR
Provider Second Line Business Practice Location Address:
SUITE 120
Provider Business Practice Location Address City Name:
NEWPORT BEACH
Provider Business Practice Location Address State Name:
CA
Provider Business Practice Location Address Postal Code:
92660-7526
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
949-640-9570
Provider Business Practice Location Address Fax Number:
949-640-9569
Provider Enumeration Date:
03/13/2017

Additional Information

Authorized Official

Authorized Official Last Name:
HENDRICKS
Authorized Official First Name:
DOUGLAS
Authorized Official Middle Name:
L
Authorized Official Title or Position:
OWNER-CEO
Authorized Official Telephone Number:
949-640-9570

Provider Taxonomy Codes

  • Taxonomy code: 261QH0100X , with the licence number:  28839 , registered in the state of CA ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 1922165703 . This is a "NPI OF PROVIDER" identifier , issued by the state of ( CA ) . This identifiers is of the category "OTHER".




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