1740251594 NPI number — PACIFICA ORTHOPEDICS

Table of content: (NPI 1740251594)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1740251594 NPI number — PACIFICA ORTHOPEDICS

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
PACIFICA ORTHOPEDICS
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:
1740251594
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:
18800 DELAWARE ST
Provider Second Line Business Mailing Address:
SUITE 150
Provider Business Mailing Address City Name:
HUNTINGTON BEACH
Provider Business Mailing Address State Name:
CA
Provider Business Mailing Address Postal Code:
92648-1959
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
714-841-5333
Provider Business Mailing Address Fax Number:
714-841-5303

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
18800 DELAWARE ST
Provider Second Line Business Practice Location Address:
SUITE 150
Provider Business Practice Location Address City Name:
HUNTINGTON BEACH
Provider Business Practice Location Address State Name:
CA
Provider Business Practice Location Address Postal Code:
92648-1959
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
714-841-5333
Provider Business Practice Location Address Fax Number:
714-841-5303
Provider Enumeration Date:
01/30/2006

Additional Information

Authorized Official

Authorized Official Last Name:
WAKIM
Authorized Official First Name:
PAUL
Authorized Official Middle Name:
Authorized Official Title or Position:
MEDICAL DIRECTOR
Authorized Official Telephone Number:
714-841-5333

Provider Taxonomy Codes

  • Taxonomy code: 111NX0800X , with the licence number:  19041 , registered in the state of CA ; information, associated with the NPI states the following Primary Taxonomy Switch: "X" .
  • Taxonomy code: 204C00000X , with the licence number: 20A4964 , registered in the state of CA ; information, associated with the NPI states the following Primary Taxonomy Switch: "X" .
  • Taxonomy code: 204C00000X , with the licence number: 20A4685 , registered in the state of CA ; information, associated with the NPI states the following Primary Taxonomy Switch: "X" .
  • Taxonomy code: 204C00000X , with the licence number: 20A4153 , registered in the state of CA ; information, associated with the NPI states the following Primary Taxonomy Switch: "X" .
  • Taxonomy code: 204C00000X , with the licence number: A70813 , registered in the state of CA ; information, associated with the NPI states the following Primary Taxonomy Switch: "X" .
  • Taxonomy code: 204C00000X , with the licence number: 17911 , registered in the state of CA ; information, associated with the NPI states the following Primary Taxonomy Switch: "X" .
  • Taxonomy code: 204C00000X , with the licence number: A29528 , registered in the state of CA ; information, associated with the NPI states the following Primary Taxonomy Switch: "X" .
  • Taxonomy code: 204C00000X , with the licence number: 20A8191 , 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: 17911 . This is a "STATE LIC#" identifier , issued by the state of ( CA ) . This identifiers is of the category "OTHER".
  • Identifier: 20A4685 . This is a "STATE LIC#" identifier , issued by the state of ( CA ) . This identifiers is of the category "OTHER".
  • Identifier: 20A4964 . This is a "STATE LIC#" identifier , issued by the state of ( CA ) . This identifiers is of the category "OTHER".
  • Identifier: 20A8191 . This is a "STATE LIC#" identifier , issued by the state of ( CA ) . This identifiers is of the category "OTHER".
  • Identifier: ZZZ05885Z . This is a "BLUE SHIELD ID" identifier , issued by the state of ( CA ) . This identifiers is of the category "OTHER".
  • Identifier: A29528 . This is a "STATE LIC#" identifier , issued by the state of ( CA ) . This identifiers is of the category "OTHER".
  • Identifier: 20A4153 . This is a "STATE LIC#" identifier , issued by the state of ( CA ) . This identifiers is of the category "OTHER".




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