Basic Information
| Provider Information | |||||||||
| NPI: | 1194936922 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | PACIFIC BREAST CARE MEDICAL GROUP, INC. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1640 NEWPORT BLVD STE 200 | ||||||||
| Address2: | |||||||||
| City: | COSTA MESA | ||||||||
| State: | CA | ||||||||
| PostalCode: | 926273786 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9495153544 | ||||||||
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| Practice Location | |||||||||
| Address1: | 1640 NEWPORT BLVD STE 200 | ||||||||
| Address2: | |||||||||
| City: | COSTA MESA | ||||||||
| State: | CA | ||||||||
| PostalCode: | 926273786 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9495153544 | ||||||||
| FaxNumber: | 9497066356 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/24/2007 | ||||||||
| LastUpdateDate: | 11/10/2010 | ||||||||
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| AuthorizedOfficialLastName: | POLICE | ||||||||
| AuthorizedOfficialFirstName: | ALICE | ||||||||
| AuthorizedOfficialMiddleName: | M | ||||||||
| AuthorizedOfficialTitleorPosition: | PRESIDENT | ||||||||
| AuthorizedOfficialTelephone: | 9495153544 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | DR. | ||||||||
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| AuthorizedOfficialCredential: | MD | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207RM1200X | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Internal Medicine | Magnetic Resonance Imaging (MRI) | 2085U0001X | Y | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Radiology | Diagnostic Ultrasound |
ID Information
| ID | Type | State | Issuer | Description | 2944453 | 01 | CA | ARTICLES OF INCORPORATION | OTHER | FNP35928 | 01 | CA | MEDICAL LICENSE FIC NAME | OTHER |