Basic Information
| Provider Information | |||||||||
| NPI: | 1639357478 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | PACIFIC CLINICS | ||||||||
| LastName: | |||||||||
| FirstName: | |||||||||
| MiddleName: | |||||||||
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| Credential: | |||||||||
| OtherOrganizationName: | PACIFIC CLINICS COMMUNITY DAY SCHOOL EL MONTE | ||||||||
| OtherOrganizationType: | 5 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 800 S SANTA ANITA AVE | ||||||||
| Address2: | |||||||||
| City: | ARCADIA | ||||||||
| State: | CA | ||||||||
| PostalCode: | 910066853 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6262545000 | ||||||||
| FaxNumber: | 6262941077 | ||||||||
| Practice Location | |||||||||
| Address1: | 5050 KINGS ROW | ||||||||
| Address2: | |||||||||
| City: | EL MONTE | ||||||||
| State: | CA | ||||||||
| PostalCode: | 917315405 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6264631021 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 02/04/2008 | ||||||||
| LastUpdateDate: | 07/22/2016 | ||||||||
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| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | BALLA | ||||||||
| AuthorizedOfficialFirstName: | JAMES | ||||||||
| AuthorizedOfficialMiddleName: | J. | ||||||||
| AuthorizedOfficialTitleorPosition: | PRESIDENT & CHIEF EXECUTIVE OFFICER | ||||||||
| AuthorizedOfficialTelephone: | 6262545000 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 251S00000X | Y | Agencies | Community/Behavioral Health |
ID Information
| ID | Type | State | Issuer | Description | 19AN | 05 | CA | MEDICAID |