Basic Information
| Provider Information | |||||||||
| NPI: | 1174822159 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | PACIFIC RIM HEADACHE CENTER | ||||||||
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| Mailing Information | |||||||||
| Address1: | 715 SEAFARERS WAY | ||||||||
| Address2: | STE 201 B | ||||||||
| City: | ANACORTES | ||||||||
| State: | WA | ||||||||
| PostalCode: | 982212257 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3605881460 | ||||||||
| FaxNumber: | 3605881473 | ||||||||
| Practice Location | |||||||||
| Address1: | 715 SEAFARERS WAY | ||||||||
| Address2: | STE 201 B | ||||||||
| City: | ANACORTES | ||||||||
| State: | WA | ||||||||
| PostalCode: | 982212257 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3605881460 | ||||||||
| FaxNumber: | 3605881473 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 03/16/2011 | ||||||||
| LastUpdateDate: | 03/01/2012 | ||||||||
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| AuthorizedOfficialLastName: | JONES | ||||||||
| AuthorizedOfficialFirstName: | JOHNNY | ||||||||
| AuthorizedOfficialMiddleName: | MICHAEL | ||||||||
| AuthorizedOfficialTitleorPosition: | OWNER | ||||||||
| AuthorizedOfficialTelephone: | 3605881460 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialCredential: | MPAS-C | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 101YM0800X | 00009893 | WA | N | 193200000X MULTI-SPECIALTY GROUP | Behavioral Health & Social Service Providers | Counselor | Mental Health | 207Q00000X | 00017410 | WA | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Family Medicine | 363A00000X | 10004470 | WA | Y | 193200000X MULTI-SPECIALTY GROUP | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant |
ID Information
| ID | Type | State | Issuer | Description | 1174822159 | 05 | WA | MEDICAID |