1871642991 NPI number — PACIFIC SHORES MEDICAL GROUP, INC.

Table of Contents

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1871642991 NPI number — PACIFIC SHORES MEDICAL GROUP, INC.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
PACIFIC SHORES MEDICAL GROUP, 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:
1871642991
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
04/12/2016
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
1043 ELM AVE
Provider Second Line Business Mailing Address:
STE 104
Provider Business Mailing Address City Name:
LONG BEACH
Provider Business Mailing Address State Name:
CA
Provider Business Mailing Address Postal Code:
90813-3271
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
562-590-0345
Provider Business Mailing Address Fax Number:
562-437-8139

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
222 W EULALIA ST
Provider Second Line Business Practice Location Address:
#100-B
Provider Business Practice Location Address City Name:
GLENDALE
Provider Business Practice Location Address State Name:
CA
Provider Business Practice Location Address Postal Code:
91204-2849
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
818-637-7611
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
01/09/2007

Additional Information

Authorized Official

Authorized Official Last Name:
TCHEKMEDYIAN
Authorized Official First Name:
NERSES
Authorized Official Middle Name:
SIMON
Authorized Official Title or Position:
CEO
Authorized Official Telephone Number:
562-590-0345

Provider Taxonomy Codes

  • Taxonomy code: 207RH0003X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: GR0065541 , issued by the state of ( CA ) . This identifiers is of the category "MEDICAID".




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