Basic Information
| Provider Information | |||||||||
| NPI: | 1053350975 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | PACIFICA EMERGENCY MEDICAL ASSOCIATES | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 80612 | ||||||||
| Address2: | |||||||||
| City: | CITY OF INDUSTRY | ||||||||
| State: | CA | ||||||||
| PostalCode: | 917168411 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3103792134 | ||||||||
| FaxNumber: | 3103794856 | ||||||||
| Practice Location | |||||||||
| Address1: | 16237 VENTURA BLVD | ||||||||
| Address2: | |||||||||
| City: | ENCINO | ||||||||
| State: | CA | ||||||||
| PostalCode: | 914362201 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3103792134 | ||||||||
| FaxNumber: | 3103794856 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/06/2006 | ||||||||
| LastUpdateDate: | 07/21/2022 | ||||||||
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| AuthorizedOfficialLastName: | EDWARDS | ||||||||
| AuthorizedOfficialFirstName: | IRV | ||||||||
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| AuthorizedOfficialTitleorPosition: | PRESIDENT | ||||||||
| AuthorizedOfficialTelephone: | 3103792134 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialCredential: | M.D. | ||||||||
| NPICertificationDate: | 05/18/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207P00000X | CA | Y | 193400000X SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Emergency Medicine |
ID Information
| ID | Type | State | Issuer | Description | GR0051721 | 05 | CA | MEDICAID |