Basic Information
| Provider Information | |||||||||
| NPI: | 1245389725 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | THE PAJO CORP | ||||||||
| LastName: | |||||||||
| FirstName: | |||||||||
| MiddleName: | |||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | |||||||||
| OtherOrganizationName: | TRI CITY INSTITUTE | ||||||||
| OtherOrganizationType: | 3 | ||||||||
| OtherLastName: | |||||||||
| OtherFirstName: | |||||||||
| OtherMiddleName: | |||||||||
| OtherNamePrefix: | |||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | |||||||||
| OtherLastNameType: | |||||||||
| Mailing Information | |||||||||
| Address1: | 2080 CENTURY PARK E | ||||||||
| Address2: | SUITE 1210 | ||||||||
| City: | CENTURY CITY | ||||||||
| State: | CA | ||||||||
| PostalCode: | 900672001 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3105539500 | ||||||||
| FaxNumber: | 3105537247 | ||||||||
| Practice Location | |||||||||
| Address1: | 2080 CENTURY PARK E | ||||||||
| Address2: | SUITE 1210 | ||||||||
| City: | CENTURY CITY | ||||||||
| State: | CA | ||||||||
| PostalCode: | 900672001 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3105539500 | ||||||||
| FaxNumber: | 3105537247 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 01/10/2007 | ||||||||
| LastUpdateDate: | 05/24/2016 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
| NPIDeactivationDate: | |||||||||
| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | PERRY | ||||||||
| AuthorizedOfficialFirstName: | CAROLYN | ||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | EXECUTIVE DIRECTOR | ||||||||
| AuthorizedOfficialTelephone: | 3105539500 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | |||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | PHYSICIAN ASSISTANT | ||||||||
| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 261QR0405X | 19.135 | CA | Y | Ambulatory Health Care Facilities | Clinic/Center | Rehabilitation, Substance Use Disorder |
ID Information
| ID | Type | State | Issuer | Description | HDC70049F | 05 | CA | MEDICAID |