Basic Information
| Provider Information | |||||||||
| NPI: | 1013360676 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | SOUTH PACIFIC | ||||||||
| LastName: | |||||||||
| FirstName: | |||||||||
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| OtherOrganizationName: | SOUTH PACIFIC | ||||||||
| OtherOrganizationType: | 4 | ||||||||
| OtherLastName: | |||||||||
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| Mailing Information | |||||||||
| Address1: | 16260 VENTURA BLVD | ||||||||
| Address2: | |||||||||
| City: | ENCINO | ||||||||
| State: | CA | ||||||||
| PostalCode: | 914362203 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8189861977 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 16260 VENTURA BLVD | ||||||||
| Address2: | |||||||||
| City: | RNCINO | ||||||||
| State: | CA | ||||||||
| PostalCode: | 91364 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8189861977 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/19/2016 | ||||||||
| LastUpdateDate: | 07/19/2016 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
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| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | COBAIN | ||||||||
| AuthorizedOfficialFirstName: | KAREN | ||||||||
| AuthorizedOfficialMiddleName: | SHAPIRO | ||||||||
| AuthorizedOfficialTitleorPosition: | PTA | ||||||||
| AuthorizedOfficialTelephone: | 8185779410 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialCredential: | PTA | ||||||||
| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 314000000X | AT1195 | CA | Y | Nursing & Custodial Care Facilities | Skilled Nursing Facility |
No ID Information.